Failure to Prevent Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for two residents, resulting in missing controlled substances and incomplete documentation. During the discharge process for one resident, discrepancies were identified in the narcotic card and sheet counts, with three cards missing and no documented explanation for their removal. The agency RN involved could not account for the missing medications or provide details on the disposition of the blister packs and count sheets. The controlled substance shift inventory sheets were not properly completed, with missing signatures and blank sections where explanations should have been provided. One resident was admitted for a respite stay under hospice care and had orders for hydrocodone-acetaminophen. Pharmacy records indicated a specific quantity of medication was received, but the medication administration record only documented the administration of three tablets during the stay. The controlled substance inventory showed a reduction of three cards without corresponding documentation or explanation. The former DON confirmed that the medications and count sheets were missing and could not be located after an internal investigation. A second resident, admitted with multiple injuries and prescribed oxycodone, also had missing narcotic medications. Pharmacy records and medication administration records did not account for all tablets received, and witness statements confirmed that medications for both residents were unaccounted for. Interviews with staff revealed that the required shift-to-shift controlled substance counts were not consistently signed by both incoming and outgoing nurses, contrary to facility policy. The facility's policy required immediate reporting and documentation of unresolved discrepancies, which was not followed in these instances.