Failure to Account for Controlled Substances During Resident Pass
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the accurate accounting and documentation of controlled substances for a resident who went out on pass. The resident, who had intact cognitive status and was prescribed opioid medications for pain management, reported that when he left the facility for a pass, an agency nurse gave him a bag with his medications but did not count the narcotics with him or provide the required narcotic sheets. Upon his return, the resident informed facility staff that the medications were not counted at the time of his departure, and staff subsequently discovered that the narcotic sheets were missing. Facility staff, including two LVNs, counted the medications upon the resident's return and created new narcotic sheets to account for what was brought back. The DON later confirmed that the process for signing out controlled substances was not followed, as there was no two-nurse count, no resident signature for the medications provided, and the narcotic sheets were not given to the resident as per protocol. The DON also acknowledged that the incident was not reported as a potential drug diversion or misappropriation at the time, despite the lack of accountability for the narcotics. Interviews with facility leadership and staff revealed that the agency nurse responsible for the resident's medications was not properly oriented to the facility's procedures for handling controlled substances during resident passes. Facility policies required written prescriber authorization, two-nurse count verification, and documentation in the controlled substance disposition log, none of which were followed in this instance. The failure to adhere to these procedures resulted in a lack of accountability for the resident's narcotic medications during his absence from the facility.