Failure to Accurately Receive and Document Controlled Substance Delivery
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and accurate documentation of controlled substances for a resident with chronic pain who had an order for fentanyl patches. The resident was admitted with a diagnosis of chronic pain and had a physician's order for fentanyl 25 mcg patches to be applied every three days. When the pharmacy delivered two fentanyl patches, an LPN signed for the delivery without verifying the contents of the pharmacy bag. The LPN only felt one blister pack of pills inside the bag, discarded the bag at the nurse's station, and handed the pills to another nurse. The fentanyl patches were not identified or logged into the narcotic addition and deletion log at the time of delivery. The missing fentanyl patches were discovered two days later when the medication was not available for administration. The LPN realized she had likely thrown away the patches with the pharmacy bag and notified the DON. Interviews with staff confirmed that the expected process was for nurses to verify and sign in narcotics upon delivery, but this was not followed. The facility's investigation did not substantiate diversion or misappropriation, but the controlled substance was not properly received, verified, or documented as required.