Failure to Maintain Accurate Receipt and Reconciliation of Controlled Drugs Awaiting Disposal
Penalty
Summary
The facility failed to establish and maintain a detailed system for the receipt and reconciliation of all controlled drugs, specifically for medications awaiting disposal. During an observation, several controlled medications, including Hydrocodone/APAP, Alprazolam, Diazepam, and Lorazepam, were found stored in a locked cabinet awaiting destruction. The Director of Nursing (DON) reported that when controlled medications were brought to her, she verified the count with a nurse and both signed the narcotic sheet before placing the medication in the locked box. However, the DON did not reconcile these medications prior to their destruction with the pharmacy consultant, and there was no record of receipt for controlled medications awaiting disposition to allow for accurate and periodic reconciliation. Record review showed that the last medication destruction was completed several weeks prior, and the facility's policy required two licensed nurses to document and witness the removal of discontinued or expired narcotics from active inventory, with proper storage and a signed destruction log. Despite these policies, the process described by the DON and Administrator did not include logging the receipt of controlled medications awaiting destruction, and reconciliation was only performed at the time of destruction. This lack of documentation and periodic reconciliation could result in incomplete records and an inability to accurately account for all controlled substances in the facility.