Failure to Ensure Proper Return and Accountability of Controlled Substances
Penalty
Summary
The facility failed to maintain effective systems for the return of controlled medications to the pharmacy for three residents who had discontinued narcotic prescriptions. For each resident, there were discrepancies between the controlled substance count records and the medication administration records (MARs), as well as inconsistencies in the documentation of medication returns. In one case, a resident prescribed hydrocodone-acetaminophen had 10 tablets remaining after discontinuation, and the return of drugs form was completed, but the medication was not received by the pharmacy. Similarly, another resident prescribed oxycodone had 17 tablets left, and a third resident prescribed oxycodone-acetaminophen had 30 tablets remaining; both medications were documented as prepared for return, but the pharmacy did not receive them. The investigation revealed that the process for returning controlled substances involved placing discontinued medications in an unsealed bag in the narcotic drawer, completing a return of drug form, and faxing the form to the pharmacy. However, there was confusion and lack of clarity among staff regarding who completed the forms and who was responsible for ensuring the medications were picked up by the pharmacy courier. The return of drug form for the missing medications was found with a courier signature that was later determined not to be authentic. Staff interviews indicated that while the medications were prepared for return and placed in the appropriate location, there was no confirmation that the pharmacy courier actually picked up the medications, and the medications were ultimately unaccounted for. The pharmacy manager confirmed that the pharmacy had no record of receiving the medications or the return of drug form, and the courier verified that the signature on the form was not hers. The facility's internal investigation, including interviews with nursing staff and audits of medication carts, was unable to determine the exact circumstances of the missing medications. The deficiency was attributed to the facility's failure to have a reliable system for verifying and documenting the return of controlled substances, resulting in unaccounted-for narcotic medications.