Failure to Reconcile and Report Discrepancy in Controlled Substance Count
Penalty
Summary
The facility failed to ensure that a resident was protected from misappropriation of controlled drugs, specifically Tramadol, by not maintaining and periodically reconciling the medication count as required. The deficiency involved a resident with multiple diagnoses, including congestive heart failure, type 2 diabetes, cardiac pacemaker, senile degeneration of the brain, and muscle wasting. The resident was admitted on 07/03/24 and was placed on hospice care, with Tramadol discontinued on 3/23/25. The resident passed away on 3/24/25. On the morning following the resident's death, a nurse discovered that the count for the resident's Tramadol was off by one tablet. The nurse who had worked the previous night shift admitted to noticing the discrepancy during her shift but did not report it immediately, nor did she conduct the required count with the outgoing nurse at shift change. The nurse stated she did not want to disturb the previous nurse and failed to follow protocol for reporting and reconciling the count. Statements from other staff confirmed that the nurse in question was frequently late and often refused to participate in the required medication counts at shift change, despite being counseled and trained on this responsibility. The facility's policy required that both the oncoming and outgoing nurses count controlled substances together at each shift change and report any discrepancies to the DON. In this case, the count was not performed as required, the discrepancy was not reported in a timely manner, and the nurse involved did not comply with requests for drug screening following the incident. The failure to follow established procedures resulted in the unaccounted loss of a controlled medication after it had been discontinued and the resident had passed away.