Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of receipt and disposition of all controlled drugs for a resident, resulting in the loss of a narcotic count sheet for one card of 30 Oxycodone 20 mg tablets. The pharmacy delivered a 30-day supply of 120 tablets, divided into four cards of 30 tablets each, and records confirmed receipt by the facility. While three of the four controlled substance sheets were available and reconciled, one sheet was missing, leaving no documentation or reconciliation for the administration of 30 tablets. The medication administration record (MAR) showed that doses were given and documented, but the corresponding narcotic count sheet for one card could not be located. Interviews with staff revealed that narcotic medications are signed in upon delivery and are supposed to be accounted for on controlled substance sheets, with reconciliation at the beginning and end of each shift. The LPN interviewed did not recall any discrepancies or resident complaints regarding pain medication. The DON confirmed the missing narcotic sheet and stated that all sheets should be accounted for, with staff expected to sign out and document administration of controlled medications. The administrator also acknowledged the expectation for accurate reconciliation of narcotics.