Failure to Document and Investigate Missing Controlled Substance
Penalty
Summary
The facility failed to properly identify, reconcile, document, and investigate a missing controlled substance, specifically Morphine Sulfate, for one resident who was under hospice care and had multiple orders for pain management, including Morphine and Fentanyl. The facility's policies required strict documentation and inventory control of controlled substances, including shift-to-shift counts, immediate reporting of discrepancies, and thorough investigation of any loss. However, for a period covering several days, there was a lack of documentation in both the Medication Administration Record (MAR) and the controlled substance count forms regarding the administration and inventory of Morphine for the resident. During this period, a contracted LPN reported administering large amounts of Morphine to the resident, but failed to document these administrations in the MAR or on the official pharmacy-generated count forms. The LPN stated that the resident was yelling throughout the night and that nearly a whole bottle of Morphine was used, but the count sheet and the empty bottle were never found. The facility's investigation into the missing Morphine was incomplete, lacking essential details such as the resident's name, and did not include interviews with pharmacy staff, the physician, other residents, or employees. Additionally, the investigation relied on informal statements and did not follow the facility's established procedures for reporting and investigating medication errors or losses of controlled substances. The facility was unable to produce required medication error reports for the relevant period, and staff interviews confirmed that no comprehensive investigation was conducted. The LPN involved had a documented history of disciplinary issues related to medication administration and documentation. At the time, the facility was also without a Director of Nursing, which contributed to lapses in oversight and follow-up regarding the missing controlled substance.