Failure to Maintain Accurate Controlled Medication Records and Investigate Missing Narcotics
Penalty
Summary
The facility failed to provide and maintain accurate records regarding a controlled medication incident involving a resident with muscle wasting, nerve damage, and moderate cognitive impairment who was prescribed tramadol for pain management. On the date in question, the Controlled Drug Count Record was not signed by a Certified Medication Assistant (CMA) at 6 AM, and a subsequent count revealed that two tramadol tablets were missing. The Individual Narcotic Record and Medication Reconciliation indicated discrepancies in the tramadol tablet count between shifts. Staff interviews confirmed that after the administration of bedtime medications, a Licensed Practical Nurse (LPN) assumed responsibility for the medication cart and discovered the missing tablets during the narcotic count with the CMA, who then refused to sign the count record and left the facility immediately. The facility's policy on the storage of medications did not include specific procedures for narcotic counting, destruction, or actions to be taken in the event of missing medication. The Regional Nurse Consultant confirmed the loss of two tramadol tablets and reported that the facility was unable to determine the cause of the missing medication. The investigation concluded without resolution as the CMA involved did not return to the facility or respond to follow-up attempts.