Unlicensed Staff Assigned to Retrieve and Transport Methadone
Penalty
Summary
The facility failed to develop and implement a procedure for the safe acquisition and receipt of physician-ordered Methadone, a controlled substance, from a third-party clinic. Instead, the facility assigned an unlicensed staff member, a Certified Nursing Assistant (CNA), to travel to the outside clinic to pick up Methadone for multiple residents. The CNA transported the Methadone in a locked box with the key in her possession, using her personal vehicle, and delivered it to the facility's nursing staff. Interviews with the CNA, the Director of Nursing (DON), and review of facility documents confirmed that this practice occurred over several weeks, and that there was no specific policy or procedure in place for this process. The facility's existing policy stated that controlled substances should be delivered and signed for by a licensed nurse, but this was not followed in the case of Methadone pickups from the clinic. Further interviews revealed that the consultant pharmacist did not consider the Methadone clinic under his jurisdiction, and the DON acknowledged the lack of a specific policy for Methadone retrieval, relying instead on a general narcotic policy. Nursing staff interviewed stated that CNAs should not handle or deliver narcotics or any type of medication, as they are not licensed to do so. The facility's corporate office also lacked a specific policy for this process. The deficiency was identified through observations, interviews, and document reviews conducted by surveyors, and was cited under relevant state regulations.