Failure to Properly Receive and Count Narcotic Medication
Penalty
Summary
A deficiency occurred when a narcotic medication, Oxycodone-Acetaminophen Oral Tablet 10-325 MG, prescribed for a resident with chronic pain due to liver cirrhosis, was not properly received and counted upon admission. The resident, who had severe cognitive impairment and multiple medical diagnoses including cirrhosis, substance abuse, hypertension, hepatitis C, and a history of repeated falls, was admitted with physician orders for the narcotic to be administered as needed for pain. Upon arrival of the medication, the responsible RN accepted the pill bottle from the hospice nurse and relied on the count listed on the bottle, failing to physically count the pills as required by facility policy. The facility's policy mandated that controlled substances be verified and counted by a licensed nurse in the presence of the delivery person, with both parties signing the delivery log. However, the RN did not follow this protocol and instead locked the medication away without verification. The off-going nurse had not seen or counted the narcotics either, and only other medications brought from home were signed in. The next day, another nurse discovered that the narcotic count was short by 15 pills when performing the routine count at the start of his shift. This discrepancy was reported to the DON, who confirmed the shortage and initiated an investigation. Interviews with involved staff revealed that the medication had been left at the hospice office for over 24 hours before being delivered, and that the required two-person verification process was not followed. The failure to properly receive and count the narcotic medication resulted in an inaccurate medication count for the resident.