Failure to Maintain Accountability for Controlled Substances
Penalty
Summary
Nurses at the facility failed to properly complete narcotic medication counts and maintain accountability for controlled substances for three out of four sampled residents. Facility policy required that controlled substances be counted and documented by two licensed nurses at each shift change, with specific procedures for liquid narcotics and storage. However, documentation and interviews revealed that nurses did not consistently count or document narcotics as required, and in some cases, signed off on counts they did not actually perform. For one resident with an order for lorazepam, discrepancies were found in the medication count, with a 2.5 ml deficit noted and no documentation of administration for the missing amount. Statements from LPNs indicated that the refrigerated lorazepam was not always counted during shift changes, and one LPN admitted to not completing the count due to time constraints and habitually delaying documentation. Another resident with an order for tramadol had a missing medication card, and the nurse involved admitted to signing out the medication for one resident but administering it to another, as well as not knowing the whereabouts of the missing card. For a third resident, hydrocodone was reportedly destroyed by a nurse after the order was discontinued, but this was done without a witness and the medication card was not located. Interviews with the Director of Nursing confirmed that nurses did not follow policy regarding narcotic counts and documentation, and that some staff signed off on counts they did not actually perform. The investigation determined that narcotics were diverted by a nurse, and that other staff failed to properly verify and document controlled substance counts as required by facility policy and regulations.