Failure to Safely Manage and Control Narcotics Resulting in Drug Diversion and Misappropriation
Penalty
Summary
The facility failed to manage and control narcotics in a safe manner, resulting in multiple incidents of missing controlled medications for all residents reviewed during the survey. In one instance, a discrepancy was identified when a staff member attempted to reorder Hydrocodone for a resident and discovered that thirty tablets were missing from the medication cart, despite pharmacy records indicating that sixty tablets had been delivered and signed for. The staff member who received the medication reported only receiving thirty tablets, while another staff member documented receipt of sixty tablets on the manifest. The facility was unable to confirm misappropriation at that time, but the missing medication was not located. Another incident involved a resident missing twenty-six doses of Oxycodone, with both the sign-out log and shift-to-shift count report also missing. The investigation substantiated misappropriation, but the responsible nursing staff could not be determined. Additional review revealed that controlled medications intended for destruction for eight other residents were missing from the lock box when the pharmacist arrived to destroy them, despite being logged for destruction. The facility could not determine how or when these medications were taken or by whom, but the misappropriation was substantiated. A further incident involved a discrepancy in the medication count for seven Hydrocodone tablets. Investigation determined that an LPN who had access to the medication cart during a shift was responsible for the missing medication. The resident involved was interviewed and denied any previous missing doses, and had full cognitive capacity as documented by a BIMS score of 15 and physician determination. The facility's policy required shift-to-shift counts and double-locked storage for controlled substances, but these procedures were not effectively followed, leading to the deficiencies.