Failure to Promptly Remove and Return Discontinued Controlled Substances
Penalty
Summary
The facility failed to have effective systems in place for the prompt return of controlled narcotic medications to the pharmacy after a resident was discharged. Specifically, oxycodone-acetaminophen prescribed to a resident with dementia and kidney stones remained stored in the medication cart after the resident's discharge, rather than being removed and returned as required. During a monthly reconciliation, it was discovered that a blister card containing 30 tablets of the controlled substance, along with its declining count sheet, was missing from the medication cart. Additionally, discrepancies were noted in the declining count sheets, including a late entry by a nurse for a dose that was not documented in the Medication Administration Record (MAR) and could not be accounted for. The investigation revealed that the Director of Nursing (DON) had conducted an audit and made copies of all narcotic count sheets, identifying that the discharged resident still had two cards of oxycodone-acetaminophen on the cart. The following day, when the DON attempted to remove the medications, one card was missing. Interviews with nursing staff indicated inconsistent practices in counting and signing off on controlled substances, with one nurse unable to recall the count or explain a missing signature, and another nurse admitting to borrowing medication for another resident without proper documentation. The pharmacist consultant, who conducted monthly checks, had not previously identified any discrepancies or discontinued narcotics left on the carts. The facility's policy required nurses to inform the DON when a controlled narcotic was no longer needed, but this process was not followed. The failure to promptly remove and return discontinued or unneeded controlled substances resulted in the misappropriation of medication. The incident led to the involvement of law enforcement, drug testing of staff, and reporting to regulatory agencies. The deficiency was attributed to lapses in pharmacy services and medication handling procedures, specifically the lack of timely removal of controlled substances from medication carts after discharge or discontinuation.