Failure to Maintain Accurate Controlled Drug Inventory and Shift Counts
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically hydrocodone/acetaminophen prescribed to a female resident with a hip fracture and severely impaired cognition. The resident was admitted with an order for hydrocodone 5 mg/acetaminophen 325 mg, and her medication was brought in by her representative. Upon arrival, the medication was counted by two nurses and a count sheet was created, but subsequent handling of the medication was inconsistent and not in accordance with facility policy. During the period under review, nursing staff did not consistently count the narcotic medications during shift changes, and not all narcotics had an associated Inventory Sheet. On one occasion, the hydrocodone/acetaminophen was not counted and lacked an Inventory Sheet. Discrepancies in pill counts were identified, with counts varying between staff and the resident's representative, and a significant number of pills were found to be missing. The MAR indicated fewer pills had been administered than the number missing from the bottle, and the required narcotic sheet for the bottle was missing at the time of the investigation. Interviews with staff revealed that nurses did not always count narcotics together at shift change, and one nurse accepted the narcotic keys without performing the required count. The facility's policy requires controlled drugs to be counted at every shift change by both oncoming and off-going staff, with counts recorded on the Narcotic Records. These procedures were not followed, resulting in an inability to accurately reconcile the controlled drug inventory and maintain proper records.