Failure to Account for and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that residents' controlled medications, specifically narcotics such as Oxycodone and Hydromorphone, were properly accounted for and not removed from the premises by staff. For five of eight sampled residents, there was a lack of documentation for the Control Disposition Records and missing blister packs of medication. The Drug Enforcement Agency (DEA) conducted an investigation following a complaint regarding missing narcotics and found that six blister packs for five residents, along with the corresponding disposition records, were unaccounted for. Residents involved had significant medical conditions, including osteomyelitis, diabetes with polyneuropathy, pressure ulcers, congestive heart failure, metabolic encephalopathy, rheumatoid arthritis, chronic obstructive pulmonary disease, neuropathy, rectal cancer, and dementia. Physician orders for these residents included as-needed administration of narcotic pain medications. Medication Administration Records indicated that the medications were administered as ordered, but upon review, the facility could not provide documentation for the receipt, administration, or destruction of several controlled substances. Interviews with staff and residents revealed that at least one resident was informed by a nursing supervisor that pain medication could not be released upon discharge, and the contracted pharmacist confirmed the delivery of the medications in question. The facility's abuse policy defines misappropriation of resident property as a form of abuse, and the absence of required records and missing medications constituted a failure to protect residents' property as required.