Failure to Investigate Missing Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate a missing controlled medication for a resident with diagnoses including bipolar disorder and schizoaffective disorder. The resident was cognitively intact and had an order for clonazepam, a Schedule IV controlled substance, to be administered twice daily. Medication Administration Records (MAR) showed that several doses of clonazepam were not administered over a period of days, with documentation indicating the medication was either refused, unavailable, or on order. On multiple occasions, nursing staff documented that the medication was not available, and pharmacy records indicated that the medication had been delivered and signed for by a nurse. The investigation revealed inconsistencies in the medication delivery and receipt process. The nurse who signed for the medication on the pharmacy packing slip later stated she did not receive the clonazepam, only another medication, and was not asked to complete a drug screen. The facility was unable to locate the medication or the signature/count log used to track controlled substances. The nurse involved had previously received training on controlled substance procedures, but there was no evidence of further education following the incident. Additionally, the facility's investigation did not include a review of the MAR and nursing notes that documented the medication's unavailability, nor was an investigation initiated when pharmacy notes indicated a refill was requested too soon. Interviews with facility administration and pharmacy staff confirmed that the medication was delivered and signed for, but the facility did not conduct a comprehensive investigation to determine the whereabouts of the missing medication or the circumstances leading to its disappearance. The facility's policy required immediate reporting and thorough investigation of such incidents, including review of employment records and documentation of investigative steps, but these actions were not fully carried out. The deficiency was identified as a failure to properly investigate the misappropriation of a controlled medication for one resident.