Failure to Maintain Accurate Controlled Substance Records and Investigate Discrepancies
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, resulting in inadequate procedures for maintaining accurate records, tracking, and timely investigation of discrepancies related to controlled substances. This deficiency was identified through observations, interviews, and record reviews involving one resident with a physician's order for Percocet and several other residents during medication storage inspections. The investigation revealed that narcotic inventory sheets (NIS) and Individual Patient's Controlled Drug Record (IPCDR) sheets were not consistently signed by incoming and outgoing nurses as required, and supervisor signatures were missing for new narcotics added to the inventory. Alterations, including the use of white-out and cross-outs, were found on inventory records, and there was a lack of reconciliation between the number of narcotic medication cards and the corresponding IPCDR sheets. Additionally, the facility's policy did not address the monitoring and review of tracking forms for narcotic card removal or the matching of IPCDR counts with new narcotics delivered. A specific incident involved a resident who was prescribed Percocet for chronic pain. The facility received two 60-count cards of Percocet, but one card went missing, and the loss was not detected until a refill request was declined by the pharmacy. The investigation found that an agency nurse altered the narcotic count, and the missing medication and IPCDR sheet were not promptly identified. The nurses counted narcotic cards without confirming the medications inside, and the removal of narcotic cards was not properly documented on the tracking form. The Director of Nursing confirmed that the tracking form for the removed cards was not completed as required, and the monthly review process failed to detect the discrepancy. During medication storage inspections, multiple cross-outs and errors were observed on IPCDR sheets for several residents, including documentation of medication refusals after removal from blister packs and inconsistent recording of wasted or refused doses. Interviews with staff revealed a lack of clarity regarding proper documentation practices, and the facility's in-service education and policies did not adequately address the prevention of such documentation errors. The facility's failure to maintain accurate and complete records, promptly investigate discrepancies, and ensure proper documentation of controlled substances led to actual and potential drug loss or diversion.