Misappropriation of Controlled Medications Awaiting Destruction
Penalty
Summary
The facility failed to ensure the security and proper handling of controlled medications awaiting destruction, resulting in the misappropriation of an unknown quantity of these medications and the associated Drug Destruction Log. The controlled medications, which included narcotics, were stored in a locked cabinet within the DON/ADON shared office. The keys to this cabinet were inconsistently managed, with the DON initially responsible but later transferring the responsibility to the ADON, who kept the keys on her person. The office itself was secured with a keypad lock, but the code was accessible to multiple staff members. At some point between 09/22/25 and 09/26/25, the ADON placed discontinued narcotics in the cabinet and organized the medication cards, but could not specify the exact number of medications present, as this information was only recorded on the missing log. On 09/30/25, when a nurse attempted to add more narcotics to the discontinued medication cabinet, it was discovered that all but one card and a few bottles of liquid medication were missing, along with the Drug Destruction Log. The facility's process required that discontinued controlled medications be counted and signed by two nurses, with the medication and log then locked in the cabinet. However, the lack of a consistent and secure key management system, as well as unclear responsibility for the storage and documentation, contributed to the loss. The DON, who had only recently started working at the facility, was unfamiliar with the facility's medication disposal policy and relied on the ADON for guidance, further compounding the lack of oversight. Interviews with staff revealed that the expectation was for controlled medications awaiting destruction to be double-locked and accessible only to authorized personnel. However, the actual practice deviated from policy, with keys being shared and stored in unsecured locations, and the office code being known to several individuals. The missing medications and log could not be accounted for, as the control drug count sheets were also missing, making it impossible to determine the exact quantity of medications lost. The facility's policies required strict adherence to federal and state regulations regarding controlled medication handling, but these procedures were not followed, resulting in the misappropriation.