Failure to Secure and Account for Narcotic Medication
Penalty
Summary
A narcotic medication, hydrocodone, intended for a resident who was admitted following a hospital stay for pneumonia and respiratory failure, was delivered to the facility by the pharmacy. The medication was received and signed for by a night shift RN, who, due to being busy, placed the narcotic on a medication tray inside the medication room without signing it in or securing it in the required locked narcotic box. The day shift RN, also occupied with other duties, did not secure the narcotic and left it in a bin on top of the shredder in the nurses' station. The medication was not properly stored or logged as required by facility policy and DEA regulations. The narcotic remained unsecured and unaccounted for until it was discovered missing two days later. The DON became aware of the missing medication and conducted an investigation but was unable to determine its whereabouts. Facility policy requires that controlled substances be immediately signed in and stored in a double-locked compartment, with access limited to authorized staff and shift counts performed. These procedures were not followed, resulting in the loss of the narcotic medication.