Failure to Reconcile Narcotic Counts Resulting in Missing Controlled Substance
Penalty
Summary
The facility failed to reconcile narcotic and controlled substance counts at the beginning and end of every shift for a resident who was receiving scheduled opioid pain medication. Clinical record review and staff interviews confirmed that nursing staff did not complete the required narcotic counts prior to exchanging keys or at shift changes, as mandated by facility policy and procedure. This lapse resulted in a missing narcotic cassette containing Tramadol, which was discovered during the process of administering medication to a resident with multiple diagnoses, including chronic pain and osteomyelitis. Multiple staff members, including RNs and an LPN, verified that narcotic counts were not performed as required, and acknowledged that it is the expectation to follow the facility's controlled substances policy. The facility's policy, dated April 2019, specifies that controlled medications must be counted at the end of each shift by both the outgoing and incoming nurse, with any discrepancies to be reported immediately to the director of nursing services. The failure to follow this policy led to the unaccounted-for controlled substance.