Failure to Properly Process and Secure Controlled Substance Medication
Penalty
Summary
A controlled substance medication, oxycodone, intended for a resident was delivered to the facility by the contracted pharmacy, but the medication was not properly processed or safely stored. The medication was signed for by an LPN and then handed over to an RN, but there was no subsequent record of the medication in the facility's narcotic logbook. The facility's policies required that controlled substances be processed by two nurses, with a count and proper documentation, but this procedure was not followed. Additionally, the medication was delivered in a white gift bag instead of the facility's standard purple plastic bag used to visually identify controlled substances, which may have contributed to the confusion. The RN who received the medication could not specifically recall receiving it, as he was reportedly distracted by sending another resident to the hospital at the time. Two staff members recalled seeing the RN receive the medication from the LPN, but the medication and associated paperwork were never located. The pharmacy's manifest documentation showed signatures from both the LPN and a second, illegible staff member, but the medication was never entered into the narcotic log or secured as required by policy. The resident for whom the medication was intended did not miss any doses of pain medication, according to the Director of Nursing, and was later sent to the hospital for unrelated medical issues. The facility's investigation found multiple failures to follow established procedures for the receipt and handling of controlled substances, including lack of proper documentation, failure to secure the medication, and deviation from standard delivery protocols.