Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled substances was kept for two residents. Facility policy required special handling, storage, disposal, and recordkeeping for controlled substances in accordance with federal and state regulations. However, discrepancies were identified in the narcotic count sheets and Medication Administration Records (MARs) for two residents who had orders for PRN oxycodone. In both cases, the controlled substance inventory did not match the documented administration, and doses were signed out without corresponding physician orders or resident requests. For one resident with chronic pain syndrome, the MAR indicated that oxycodone was administered multiple times by a single nurse, despite the resident stating he had not requested or taken the medication for nearly two months. The medication was discontinued by the physician after this was discovered. For another resident with chronic migraines, the controlled substance count decreased by two tablets during a night shift, but only one dose was documented as given. The resident confirmed she had not requested the medication during that time. In both cases, the nurse responsible admitted to diverting the narcotics for personal use. Additionally, the facility failed to maintain proper dual signatures for narcotic counts during shift changes, as required by policy. Multiple interviews with nursing staff confirmed that several shifts lacked the required signatures in the controlled substance inventory count books across different wings of the facility. This lack of proper documentation and reconciliation of controlled substances contributed to the inability to promptly detect and prevent the diversion of medications.