Failure to Secure and Account for Controlled Substance Results in Missing Medication
Penalty
Summary
Facility staff failed to secure a controlled substance, specifically oxycodone, for a resident with multiple medical conditions including a right femur fracture, osteoporosis, major depressive disorder, pain, reduced mobility, falls, obesity, and anemia. The resident had moderately impaired cognition and was receiving both scheduled and as-needed pain medication. On the afternoon following a pharmacy delivery, a nurse attempted to administer an as-needed dose of oxycodone but discovered the medication was missing from the medication cart and safe. Investigation revealed that the pharmacy had delivered a card of 18 oxycodone 5mg tablets, which was signed for by an LPN. The facility's policies required that controlled substances be properly signed in, counted, and secured in a locked compartment immediately upon receipt. However, the medication and its count sheet were not found during searches of all medication carts and lock boxes. The nurse who signed for the medication was unable to account for its whereabouts, and the missing medication was not recovered despite a review of camera footage and interviews with staff present at the time of delivery. The incident was reported to the pharmacy, facility administration, and the resident's physician. The facility's investigation confirmed that the required procedures for signing in and securing the controlled substance were not followed, resulting in the loss of the medication. The resident's pain management was temporarily affected until replacement medication was provided.