Failure to Reconcile Narcotic Medication Upon Delivery
Penalty
Summary
The facility failed to ensure that narcotic pain medication was properly reconciled upon delivery from the pharmacy for a resident diagnosed with dementia, pain disorder, and hypertension. On 9/21/25, an LPN signed for the delivery of 30 oxycodone-acetaminophen 7.5-325 mg tablets but did not follow the facility's procedure for reconciling the controlled medications with the delivery slip before signing. The LPN placed the medications in the locked drawer on the medication cart but did not immediately record them on the narcotic disposition record as required by facility policy. The medication for the resident was never located after delivery. The resident's clinical record indicated a physician's order for oxycodone-acetaminophen as needed for pain, which was active at the time of the incident. The LPN later provided a written statement acknowledging that she did not thoroughly review the medications listed on the delivery document and could not recall any medication delivered for the resident. The facility's policy required immediate recording of controlled medications on the appropriate drug disposition record by the nurse accepting the delivery, which was not followed in this instance.