Failure to Reconcile Controlled Medication Results in Missing Tramadol
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of their medication, specifically Tramadol, by not following established procedures for receiving and reconciling controlled substances. According to the facility's policies, controlled substances are to be verified upon receipt by both the receiving nurse and the individual delivering the medication. However, on the date in question, the nurse who received the delivery did not verify the quantity of Tramadol tablets received and simply signed the paperwork before passing the medication to another nurse. As a result, 60 tablets of Tramadol and two corresponding count sheets were found to be missing, and the discrepancy was only discovered when the pharmacy denied a refill request, citing a recent delivery. The resident involved had medical diagnoses including depression, anxiety, osteomyelitis, and a history of breast cancer, and had a physician's order for Tramadol 50 mg to be administered four times daily. Review of the medication administration records indicated that all doses were documented as given according to the order, but the lack of proper reconciliation and missing count sheets made it impossible to account for all the medication. The Director of Nursing confirmed the failure to follow the reconciliation process and was unable to determine what happened to the missing medication.