Failure to Maintain Accurate Controlled Substance Records Resulting in Missing Medication
Penalty
Summary
The facility failed to maintain an established system of records for the receipt and disposition of all controlled drugs, resulting in the inability to accurately reconcile controlled substances for one hall and one resident who had orders for controlled medications. Specifically, the facility did not ensure that employees with access to controlled medications properly counted the inventory, and approximately 23 tablets of Hydrocodone, along with the corresponding medication card and narcotic log, were missing from the medication cart. Staff statements indicated that the medication card was present at the end of one shift but was missing at the start of another, and no staff member could account for its disappearance. The required narcotic count sheets and logs were not completed or were missing, and the facility was unable to determine how the medication and log went missing. The resident involved was a male with end stage renal disease requiring dialysis, as well as other significant medical conditions including dyspnea, hyperkalemia, fluid overload, and pain related to a recent surgical procedure. He was prescribed Hydrocodone-Acetaminophen for pain management, with orders for administration every four hours as needed. Documentation showed that the resident had not missed any doses of his pain medication, as another card of the same medication was available and used during the period in question. However, the facility's failure to maintain accurate records and perform proper shift-to-shift narcotic counts led to the loss of both the medication and the narcotic log, and staff were unable to provide an explanation for the discrepancy. Interviews and record reviews revealed that staff who had access to the medication cart denied diverting the medication and tested negative for controlled substances. The facility's policies required verification and documentation of controlled medication receipt, shift-to-shift counts, and immediate reporting of discrepancies, but these procedures were not followed in this instance. The missing medication and log were never located, and the facility was unable to identify the individual responsible for the loss or diversion of the controlled substance.