Failure to Obtain Required Witness Signatures During Controlled Substance Destruction
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation, as required by state and federal regulations. Specifically, on one occasion, the drug destruction record for controlled substances did not contain the required two witness signatures at the time of disposal. The record for that date was signed only by the consultant pharmacist and the DON, missing the second witness signature as mandated by facility policy and Texas Administrative Code. This lapse was identified during a review of drug destruction records covering a five-month period. Interviews with facility staff confirmed that the DON was responsible for drug destruction and was unsure how the witness signature was missed on the controlled substances sheet. The facility's policy and state regulations require that the destruction of controlled substances be witnessed by two qualified individuals, such as the administrator, DON, acting DON, or a licensed nurse, and that proper documentation be maintained. The absence of the second witness signature on the destruction record constituted a failure to follow these requirements.