Failure to Document Medication Reconciliation Leads to Controlled Substance Error at Discharge
Penalty
Summary
The facility failed to have an effective process in place to ensure the proper receipt and disposition of all controlled drugs, specifically during the discharge process. Staff did not document medication reconciliation upon discharge for one resident, which resulted in a card containing 30 Percocet (oxycodone-acetaminophen) 5-325 mg tablets, prescribed for a different resident, being sent home with the wrong individual. The resident who received the medication in error did not have an order for Percocet, while the resident for whom the medication was intended had already been discharged and did not receive it. Review of records showed that the medication reconciliation list was not completed for the discharged resident, and the narcotic record sheet for the intended recipient showed no tablets administered and no documentation of medication disposition. Staff interviews revealed inconsistencies and lapses in the process for handling and documenting controlled substances during discharge. The charge nurse did not verify each medication card against the medication list, and the process was rushed, leading to the error. Additionally, the nurse responsible did not follow the established procedure of confirming each medication one card at a time with the resident's orders and the reconciliation sheet. Further, the error was not reported promptly to the facility Administrator. The Director of Nursing was made aware of the missing narcotics on the day of the incident but failed to report the issue to the Administrator or regulatory authorities in a timely manner. This delay in reporting contributed to the prolonged period before the error was identified and addressed. The facility's policies required documentation and verification steps that were not followed, resulting in the mismanagement of controlled substances during the discharge process.