Narcotic Diversion and Documentation Failures
Penalty
Summary
The facility failed to ensure the protection of narcotic medications from diversion, resulting in 21 missing Oxycodone tablets for a resident with a history of traumatic subdural hemorrhage and chronic obstructive pulmonary disease. A physician's order was in place for Oxycodone 5 mg to be administered as needed for pain. The controlled substance record indicated that a registered nurse signed as having destroyed 21 tablets, but the documentation was incomplete, with a crumpled and partially missing form and no valid witness signature. The nurse later claimed to have destroyed the medication by mistake and stated that a qualified medication aide had witnessed the destruction, but the aide denied any involvement or witnessing of the event. Further investigation revealed that the nurse had removed the Oxycodone card and narcotic sheet from the medication cart and took them to another unit while administering flu shots, rather than following proper procedures for medication destruction. The nurse also took the narcotic sheet home and later provided a photograph of the damaged document. Surveillance footage did not show the nurse interacting with the alleged witness or destroying medications. Additionally, a broader audit uncovered discrepancies involving Oxycodone for at least seven more residents, with approximately 348 tablets unaccounted for and missing medication cards and narcotic sheets for discharged residents. The facility's policy required that all controlled substances be stored, recorded, accounted for, and destroyed according to state regulations, with destruction to be witnessed by appropriate staff. However, the nurse involved failed to adhere to these protocols, falsified records, and misappropriated resident narcotic medications. The incident was reported to the appropriate authorities, and the nurse was suspended and subsequently terminated following the investigation.