Failure to Account for Receipt and Disposition of Controlled Substances
Penalty
Summary
The facility failed to establish and maintain a system for accurately recording the receipt and disposition of controlled medications for multiple residents. For five of eight sampled residents, including individuals with diagnoses such as osteomyelitis, diabetes with polyneuropathy, pressure ulcers, congestive heart failure, metabolic encephalopathy, rheumatoid arthritis, chronic obstructive pulmonary disease, rectal cancer, and dementia, the facility was unable to provide documentation accounting for the administration and destruction of controlled substances, specifically Oxycodone and Hydromorphone. Pharmacy shipment records confirmed delivery of these medications, but the corresponding Control Disposition Records and blister packs were missing. A Drug Enforcement Agency (DEA) investigation was initiated following a complaint regarding missing narcotics. The DEA's review revealed that six blister packs for five residents, along with the required Control Disposition Records, were unaccounted for. Interviews with facility staff, including the contracted pharmacist and the Regional Director, confirmed that the facility could not produce documentation for the controlled substances delivered and that discontinued drugs were not removed from units or disposed of in a timely manner. In one instance, a resident was discharged without receiving their prescribed pain medication, and staff informed the resident that the medication could not be released to them. Further interviews with the Medical Director and review of facility documentation indicated discrepancies between Medication Administration Records, Controlled Substance Disposition sheets, and the actual presence of medications. The Medical Director noted that medication carts were overfilled and that some medications were missing or not properly documented. The facility was unable to provide a policy regarding the receipt and disposition of controlled substances that was in place prior to the incident, further highlighting the lack of an effective system for managing controlled medications.