Failure to Prevent Diversion of Discontinued Narcotic Medication
Penalty
Summary
The facility failed to implement effective safeguards and systems to prevent the diversion of discontinued narcotic pain medication, specifically Hydrocodone-Acetaminophen 5-325 mg tablets, resulting in 20 missing tablets for one resident. The resident, who was cognitively intact and had a history of stage IV and stage II pressure wounds, was re-admitted with orders for Hydrocodone-Acetaminophen. Two separate physician orders were issued: one from the hospital and another from the facility physician, but the second order was not entered into the electronic medical record. Medication deliveries were signed in by nursing staff, and declining count sheets were maintained, but discrepancies arose between the count sheets and the Medication Administration Record (MAR), with some administrations not documented on the MAR and some signatures on the count sheet being illegible. The process for handling controlled substances was not consistently followed. The order for 54 tablets was not entered into the electronic record, and the medication card remained on the medication cart beyond the 14-day period specified in the order. Nursing staff failed to remove the discontinued medication card from the cart and return it to the pharmacy as required. During shift counts, it was discovered that the count on the narcotic sheet had been altered, with 20 tablets unaccounted for. Interviews with staff revealed confusion about responsibilities for removing discontinued medications and inconsistent practices regarding shift counts and documentation. Consultant pharmacists conducted periodic audits but did not review the specific resident's medication card during the relevant period. Communication lapses were noted between the nurse practitioner, nursing staff, and the DON regarding order entry and medication management. The facility substantiated the misappropriation of the resident's property, and the investigation was unable to determine who took the missing medication. The resident reported no issues with pain management and did not experience any missed doses, but the facility's failure to maintain accurate records and secure discontinued controlled substances led to the deficiency.