Failure to Remove Discontinued Narcotic Medication Leads to Missing Tablets
Penalty
Summary
The facility failed to act on the consultant pharmacist's recommendation to remove a discontinued narcotic pain medication, Hydrocodone-Acetaminophen 5-325 mg, from the medication cart after the order for a resident was discontinued. The resident, who had been re-admitted with a stage IV pressure wound and osteomyelitis, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain, which was completed as ordered. However, a subsequent delivery of 54 tablets was received and partially administered, with the order discontinued after 14 days. Despite the consultant pharmacist's note in the August pharmacy report instructing the removal and return of the discontinued medication, the medication remained on the cart. A random audit by the consultant pharmacist identified the issue, and the recommendation to remove the medication was communicated to the DON but was missed in error. As a result, 20 tablets of the discontinued narcotic were found to be missing when the count was checked several months later. Staff interviews confirmed that the pharmacist's recommendations were not routinely followed up on, and the DON acknowledged responsibility for acting on the monthly pharmacy reports but failed to do so in this instance.