Failure to Account for and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure that drug records for a resident were properly maintained and that all controlled drugs were accounted for and periodically reconciled. Specifically, there was a missing count of hydrocodone for a resident with severe cognitive impairment and multiple medical diagnoses, including muscle weakness, pneumonia, and intellectual disability. The resident had an open-ended physician order for hydrocodone-acetaminophen as needed for pain, but medication administration records and controlled drug count sheets showed discrepancies in the number of pills received, administered, and remaining. On the morning in question, the nurses responsible for the medication cart did not perform the required narcotic count at shift change. This lapse was acknowledged by the staff involved, who could not provide a reason for failing to conduct the count. Later, during the evening shift change, it was discovered that a blister pack containing 30 hydrocodone tablets was missing. The staff and management were unable to locate the missing medication or the associated count sheet, and there were inconsistencies between the electronic medical record, paper count sheets, and the actual administration of the medication. Interviews with staff revealed that the system for monitoring controlled substances relied on shift change counts, but this process was not consistently followed. Further review of records and interviews indicated that the facility had received multiple cards of hydrocodone from both the pharmacy and hospice, but the documentation did not match the quantities received, administered, or remaining. The Director of Nursing, Assistant Director of Nursing, and Administrator were unaware of the discrepancies until notified by the surveyor. The pharmacy consultant and supervisor were also not informed of the missing medication at the time of the incident. The failure to conduct required shift change counts and maintain accurate records led to an official unknown count of hydrocodone, with a significant number of pills unaccounted for.