Failure to Safeguard and Account for Controlled Medication
Penalty
Summary
The facility failed to implement effective systems to safeguard a resident's controlled medication, resulting in the misappropriation of 30 tablets of oxycodone 15 mg for one resident. The resident, who was cognitively intact and had chronic pain syndrome, was admitted with an order for oxycodone 15 mg every six hours. The pharmacy delivered 120 tablets in four cards, and the medication was verified and signed in by two nurses. However, the medication was not started immediately due to leftover tablets from a previous order. When the supply was nearly exhausted, it was discovered that one card of 30 tablets and its corresponding declining count sheet were missing, as well as the shift change count sheet for the relevant period. Interviews with nursing staff revealed that the medication count was verified upon delivery, but the missing card and documentation were not noticed until the resident was nearly out of medication. The nurse who initiated the last card did not realize that the previous card was missing and simply used the remaining card in the cart. The Director of Nursing (DON) and other staff searched for the missing medication and documentation but were unable to locate them. The investigation included reviewing packing slips, count sheets, and interviewing staff, but the missing medication and documentation could not be accounted for. The facility reported the loss to the appropriate authorities, including the Drug Enforcement Administration and local police. Despite drug testing staff and conducting interviews, the investigation could not confirm whether the medication was diverted or accidentally discarded. The resident did not miss any doses, as additional medication was obtained before the supply was exhausted. The incident highlighted a failure in the facility's system for tracking and safeguarding controlled substances, as evidenced by the missing medication, declining count sheet, and shift change documentation.