Failure to Accurately Account for Controlled Substance During Narcotic Count
Penalty
Summary
A deficiency occurred when a nurse failed to properly verify and account for a resident's controlled medication, specifically Morphine Sulfate Oral Solution, during a required narcotic count. The nurse, LVN C, signed off on the narcotic count based on another nurse's statement that the medication was in the refrigerator, without physically checking or confirming its presence. Subsequent review and interviews revealed that the morphine was missing and could not be located, despite being required to be stored in a double-locked medication cart and included in the shift-to-shift narcotic count. The resident involved was an elderly female with multiple diagnoses, including severe cognitive impairment, polyosteoarthritis, osteomalacia, and dementia. She had a physician's order for morphine to be administered as needed for pain, but her pain assessment at the time indicated no pain. The last documented administration of the morphine was several days prior to the incident. The facility's narcotic count records and staff interviews confirmed that the medication was present during previous counts, but was unaccounted for during the shift change involving LVN C. Interviews with nursing staff and review of facility policy confirmed that the standard procedure required both the oncoming and outgoing nurses to physically verify and count all controlled substances at each shift change. The failure to follow this procedure by not physically verifying the presence of the morphine led to the medication being unaccounted for. The incident was reported to the Director of Nursing, and the missing medication was not found despite a search. The facility's policy and staff statements emphasized the importance of accurate narcotic counts to ensure all medications are accounted for at all times.