Failure to Maintain Accurate Narcotic Drug Records
Penalty
Summary
The facility failed to ensure that narcotic drug records were properly maintained and that an accurate account of all controlled drugs was kept for one of three narcotic books reviewed. According to the facility's policy, nursing staff are required to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses reconciling and documenting the count, and reporting any discrepancies to the Director of Nursing Services (DNS). However, a review of records revealed that narcotic medication for two residents was missing and unaccounted for, and the facility was unable to determine what happened to the missing medication. Staff interviews confirmed awareness of the missing narcotic medication but did not provide information on its whereabouts. The deficiency was identified when a former DNS discovered two missing narcotic cards during a review of the facility's narcotic books. Subsequent investigation and staff interviews indicated that the required procedures for reconciling and documenting controlled substances were not followed, resulting in the loss of narcotic medication. The lack of proper record-keeping and reconciliation placed residents at risk for drug diversion.