Failure to Investigate and Document Missing Controlled Medication
Penalty
Summary
Facility staff failed to complete an investigation regarding missing controlled narcotic medication for one resident after three doses of clonazepam were found to be unaccounted for. The facility's policies require that all discrepancies in controlled medication counts be urgently investigated, with all involved parties interviewed, and documentation maintained in the administrator's office. Despite these requirements, staff did not document an investigation or the results of any inquiry into the missing medication, nor did they record the discrepancy in the resident's chart or on the controlled medication sheet. The resident involved had been admitted with generalized weakness and a right femur fracture and had an active order for clonazepam. Staff records showed a discrepancy in the count of clonazepam tablets, with three doses missing and circled on the count sheet. However, there was no documentation in the resident's progress notes or other records to indicate that an investigation was conducted or that the required steps outlined in facility policy were followed. Interviews with staff, including a CMT, an LPN, the DON, and the administrator, revealed a lack of clarity regarding responsibility for investigating and documenting medication discrepancies. The DON acknowledged awareness of the discrepancy but did not document any investigation or notify the appropriate authorities as required by policy. The administrator confirmed that staff did not follow facility policy regarding the investigation and documentation of controlled medication discrepancies. The DON stated that the issue was attributed to a counting error on admission but could not confirm whether the pills were miscounted or actually missing. There was no evidence that the incident was reported to the Division of Health and Senior Services hotline or that the pharmacist was notified, as required by facility guidelines.