Failure to Document Receipt and Disposition of Controlled Drugs
Penalty
Summary
The facility failed to establish and maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation for a resident who was prescribed Oxycodone HCl. Record review showed that the resident, an older female with chronic diastolic heart failure, hypertension, and chronic pain, was ordered Oxycodone HCl as needed for pain. Upon discharge, the resident refused to take her PRN oxycodone and was picked up by a family member. However, there was no documentation of the receipt or disposition of the controlled medication, and staff interviews revealed inconsistent practices and a lack of written logs for tracking controlled substances left behind by discharged residents. Staff interviews indicated that the Director of Nursing (DON) was responsible for logging and managing narcotics and discharge records, but the DON was unable to provide a log for the medication in question. The facility relied on an electronic device for medication tracking but did not utilize written logs, and staff described varying protocols for handling medications left by discharged residents. The facility's policy required maintaining detailed records for controlled drugs, but this was not followed in the case of the resident's Oxycodone HCl, resulting in a failure to accurately reconcile controlled medications.