Failure to Reconcile and Account for Controlled Substances Resulting in Diversion
Penalty
Summary
The facility failed to maintain an effective system for the reconciliation of controlled medications, resulting in the diversion of at least 369 Oxycodone tablets across all four hallways reviewed. A medication discrepancy was identified with a resident's pain medication, prompting notification of the Executive Director, Director of Nursing Services, physician, Power of Attorney, pharmacy, police, and Adult Protective Services. A registered nurse was suspended and later terminated following the investigation. A pharmacy audit covering a one-month period revealed that 7 out of 14 residents audited did not have the required two nursing signatures on Transfer/Destruction sheets, and 8 out of 14 residents were missing Reconciliation Forms from the narcotic logs. Additional discrepancies were found during a broader audit, with at least 7 more residents affected and approximately 348 Oxycodone tablets unaccounted for. Medication cards and narcotic sheets for discharged residents were also missing. Interviews confirmed that the Regional Director of Clinical Services conducted a narcotic audit specifically for Oxycodone discrepancies, and the findings included missing documentation and unaccounted medication. The facility's policy required shift change verification of controlled substances and proper documentation for destruction, but these procedures were not consistently followed. The lack of adherence to established protocols for storage, documentation, and destruction of controlled substances led to the diversion and unaccounted loss of narcotic medications.