Failure to Investigate and Secure Controlled Substances
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation of misappropriation of resident property, specifically related to the disappearance of a controlled substance prescribed to a resident. The resident had physician orders for Oxycodone HCL and Tylenol Extra Strength for pain management. Documentation showed that the Oxycodone card and associated tracking sheet were missing from the narcotic drawer when the resident requested pain medication, resulting in a delay in administration. The shift change count sheets and narcotic records were also found to be incomplete or missing, and the original documentation was later discovered in a recycle bin, unsigned by one of the nurses involved. Staff interviews and facility documentation revealed that only two RNs had access to the medication cart during the relevant period. There was no evidence that all necessary staff interviews were conducted, including with the resident, nor was there evidence that staff drug screening was required, requested, or offered. The facility was unable to account for the missing Oxycodone or the corresponding drug count record, and the investigation did not identify a perpetrator. The facility did file a report with the local police department, but the internal investigation was incomplete as key documentation and interviews were lacking. Additionally, during a facility inspection, medication rooms were found unlocked with medications left unsecured on the counter, contrary to policy requirements for controlled substances. The Director of Nursing confirmed that original shift change count sheets were missing, and only copies were available for review. The failure to follow established procedures for handling, documenting, and investigating the loss of controlled substances resulted in a deficiency related to the misappropriation of resident property.