Failure to Ensure Integrity and Accurate Documentation of Controlled Substance Destruction
Penalty
Summary
The facility failed to ensure the integrity and security of controlled substances and did not maintain accurate narcotic destruction records as required. Specifically, an LPN forged another nurse's initials on a controlled drug record when wasting a dose of oxycodone with acetaminophen for a resident. The incident occurred when the LPN wasted the medication and, instead of having another nurse physically witness and sign the destruction as required by policy, entered the other nurse's initials at the latter's verbal request. This action resulted in inaccurate documentation of the controlled substance destruction process. The resident involved had multiple complex medical conditions, including a recent hip fracture, joint replacement, malignancies, diabetes with neuropathy, and impaired cognition. The resident was dependent on staff for mobility and had frequent incontinence. The medication in question was prescribed for pain management and was discontinued later in the month. The facility's policy required that the destruction of controlled substances be witnessed and properly documented, including signatures of both the nurse performing the destruction and the witness, which did not occur in this instance.