Narcotics Improperly Stored in Unsecured Office Desk
Penalty
Summary
The facility failed to provide proper pharmaceutical services to ensure the accurate acquiring, receiving, and accounting of all drugs, specifically narcotics, for eight residents. Eight cards of narcotic medications, including oxycodone, hydrocodone-acetaminophen, oxycodone-acetaminophen, and tramadol, were found unsecured in the former Director of Nursing's (DON) office desk drawer, which was not locked. Facility policy requires that narcotics be stored under a double lock system, counted at the beginning and end of each shift, and that discontinued narcotics be placed in a locked box in the medication room with their narcotic sheets attached. The medications found included various quantities of narcotic pain relievers for eight different residents, all with original order or fill dates documented. Interviews with staff, including an LPN, a Certified Medication Technician (CMT), the interim DON, and the Administrator, confirmed that narcotics are to be stored in a locked medication cart or medication room, always behind two locks, and never in an office or desk. Staff were unaware of why the narcotics were found in the former DON's office and reiterated that this was not in accordance with facility policy. The police were involved and confirmed the discovery and removal of the medications for investigation. The facility census at the time was 64.