Failure to Prevent Diversion of Controlled Substances
Penalty
Summary
The facility failed to ensure that medications, specifically controlled substances, were not diverted for two residents. For one resident with diagnoses including hyperlipidemia, GERD, and heart failure, there were discrepancies between the Medication Administration Record (MAR) and the Individual Control Drug Record for Hydrocodone-Acetaminophen. The MAR showed limited administration of the medication, while the control record indicated it was signed out multiple times, including after the medication had been discontinued. This discrepancy was identified through review of records and staff interviews, revealing that the medication was signed out five times after discontinuation and not reflected on the MAR. For another resident with cellulitis, sepsis, and type 2 diabetes, similar inconsistencies were found. The MAR indicated that Oxycodone was administered only three times, but the control drug record showed it was signed out seventeen times. There were visible signs of alteration on the narcotic sheet, including overwritten entries and inconsistent documentation patterns. Staff interviews and an internal audit confirmed that the narcotic logs and MAR did not correspond, and the control drug record appeared tampered with. The investigation identified a registered nurse as the staff member responsible for the discrepancies. The nurse had signed off on medication administration that was not documented in the MAR and was found to have a history of a misdemeanor and an active warrant. The facility's process for counting and documenting controlled substances was described by staff, but the records showed that the required documentation and reconciliation between the MAR and narcotic sheets were not maintained, leading to the diversion of controlled substances.