Failure to Follow Controlled Substance Procedures Leads to Unaccounted Narcotic
Penalty
Summary
The facility failed to follow its established pharmacy procedures for controlled substances, resulting in an unaccounted-for narcotic medication for one resident. According to the facility's policy, licensed nurses are required to compare the last recorded medication count in the Electronic Health Record with the physical medication package at the time of administration and update the count accordingly. However, during a review of a Facility Reported Incident, it was found that one tablet of Hydrocodone 5/325 mg was missing from a resident's medication supply. The missing tablet was not identified until an audit was conducted, revealing that the medication had been unaccounted for since a previous date. The facility's investigation was unable to determine the root cause of the missing medication. The report indicates that the required shift-to-shift narcotic counts were not consistently performed, which contributed to the delay in identifying the missing medication. The process for monitoring narcotic counts was not included in the facility's Quality Assurance Program Improvement (QAPI) at the time of the incident. Interviews with facility leadership confirmed that there was no additional information regarding the investigation, and the process for narcotic count audits was still under development.