Failure to Accurately Reconcile and Destroy Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation and secure destruction of controlled substances for six residents, resulting in the loss and diversion of narcotic medications. A police report indicated that a former employee was found in possession of medications and empty packages that had been prescribed to multiple discharged residents, including hydrocodone, clonazepam, gabapentin, lorazepam, oxycodone, and morphine. Facility records showed that destruction logs for these medications were missing for several months, and the logs that were available did not contain the required details such as resident names and correlating medications. Interviews with facility staff revealed inconsistencies and lapses in the medication destruction process. The DON stated that medication destruction was supposed to be performed weekly with a log maintained, and that both the facility and pharmacy had keys to the disposal system. However, the DON also acknowledged that the pharmacy did not reconcile medications with facility staff during destruction. A trained medication aide admitted to signing off on narcotic logs without always witnessing the destruction, especially during busy periods. Facility policy required that controlled substances be destroyed in the presence of two licensed nurses, with detailed documentation including the resident's name, medication, and prescription number. Despite this, the facility's destruction records lacked this information, and there was no evidence that the required procedures were consistently followed. This failure in process and documentation allowed for the diversion of controlled substances by a former employee.