Failure to Prevent Misappropriation of Controlled Substances by RN
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for three residents when a registered nurse (RN) repeatedly signed out duplicate doses of narcotics. The RN signed out additional doses of hydrocodone and clonazepam for multiple residents, beyond what was ordered and documented in the medication administration records (MAR). These additional doses were not properly recorded or accounted for, and there was no documentation in the residents' progress notes regarding the administration or disposition of these extra medications. The affected residents had significant medical conditions, including hypertensive heart disease with heart failure, chronic respiratory failure, age-related cognitive deficits, pain related to prosthetic joint fractures, dementia, and chronic pain. All three residents were noted to have some level of cognitive impairment, which would have limited their ability to recognize or report discrepancies in their medication administration. The discrepancies were identified when staff noticed mismatches between the number of pills in the medication bubble packs and the controlled substance verification sheets. Interviews with staff revealed that the process for counting and reconciling controlled substances was not consistently followed according to facility policy. One nurse would count the pills while the other confirmed the number on the reconciliation sheet, rather than both visually verifying the count together. The RN involved did not provide adequate documentation for the additional doses and was unable to recall specific details about the administration of the medications. The issue was discovered after a medication error was reported, leading to an internal investigation that confirmed repeated medication errors and inaccurate medication counts by the RN.