Failure to Accurately Account for Controlled Substance Due to Incomplete Narcotic Count
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate accounting of a resident's narcotic medication, specifically Lorazepam Intensol Oral Concentrate. The resident, a male with diagnoses including depression, anxiety, acute systolic heart failure, and respiratory failure, had an active physician order for Lorazepam to be administered four times daily. On a specific date, the narcotic count sheet for this medication showed a discrepancy: four syringes were missing from the count, and the count was subsequently corrected by administrative staff after the discrepancy was discovered. Interviews with nursing staff revealed that at the shift change, the outgoing and incoming nurses did not physically count the Lorazepam stored in the refrigerator, instead relying on the paper record. Both nurses admitted to not counting the medication in the refrigerator, which led to the failure to account for the missing syringes. One nurse stated she had taken all four syringes at the start of her shift and kept two in her pocket for later administration, but could not account for the missing doses. The facility's policy required all controlled substances, including those in the refrigerator, to be counted at each shift change by two staff members, but this procedure was not followed. The incident was further complicated when one of the nurses involved refused to complete a required drug test after providing a urine sample with an abnormal temperature, as per facility protocol for missing narcotics. The missing medication was not located despite a search of all medication carts and interviews with involved staff. The resident did not miss any doses of Lorazepam as the medication was replaced, but the failure to properly account for and secure controlled substances constituted a deficiency in pharmaceutical services.