Failure to Accurately Account for Controlled Narcotic Medications
Penalty
Summary
The facility failed to ensure accurate accounting of controlled narcotic medications for two residents, resulting in seven narcotic pain medication tablets being unaccounted for. According to the facility's Controlled Substances Policy, all controlled substances must be stored securely and an accurate inventory maintained at all times, with each administration and remaining quantity documented by licensed nursing personnel. However, review of medication administration records and controlled drug accountability records revealed discrepancies in the counts of Hydrocodone-Acetaminophen (Norco) for two residents, with missing tablets not accounted for by any documented administration or disposal. For one resident with dementia and right leg pain, the records showed a reduction in the number of Norco tablets without corresponding documentation of administration or disposal. Similarly, for another resident with senile dementia and adult failure to thrive, the count of Norco tablets decreased by four tablets with no documentation to explain the discrepancy. The issue was discovered during a change of shift narcotic count, which initially showed no discrepancies, but a later count revealed the missing tablets. The Director of Nursing was notified, and law enforcement was contacted to investigate the missing narcotics. Interviews with staff involved in the medication administration and shift change counts indicated that the nurse responsible for the medications could not account for the missing narcotics and denied knowledge of their whereabouts. The audit and investigation confirmed that the missing narcotics were not found in the medication cart or elsewhere, and the required documentation for administration or disposal was absent. The failure to maintain accurate records and account for all controlled substances constituted a deficiency in pharmaceutical services provided to the residents.