Failure to Account for and Secure Controlled Substance Due to Missed Shift Change Narcotic Count
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident. Specifically, a resident with diagnoses including sleep apnea, morbid obesity, and epilepsy was prescribed Modafinil 100 mg tablets for sleepiness related to sleep apnea. The medication, consisting of 30 tablets, was delivered by the pharmacy and signed for by a nurse, but was never administered to the resident and was reported missing the following day. The investigation revealed that the medication was received by one nurse and handed over to another, who reported placing it in the narcotic storage box with the pharmacy's count sheet. However, during the subsequent shift change, the required narcotic count was not performed by the two nurses responsible. Both nurses admitted in interviews that they did not count the narcotics together at shift change, contrary to facility policy. One nurse stated she counted the narcotics alone, while the other left the cart keys in the narcotic book and did not participate in the count. The medication and the count sheet were subsequently discovered missing, and a search of all medication carts and rooms failed to locate the missing Modafinil. Facility records and interviews confirmed that the required procedures for controlled substance accountability were not followed. The facility's policy mandates that controlled substances be signed for by two nurses, immediately recorded, and stored securely, with counts performed at each shift change. The failure of the nurses to conduct the shift change narcotics count and properly secure the medication led to the loss of the resident's Modafinil, with no resolution as to its whereabouts.