Failure to Accurately Account for and Administer Controlled Substances
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for a resident prescribed liquid morphine for pain management. There were multiple discrepancies in the narcotic count sheets, medication administration records (MAR), and the actual physical count of the medication. Specifically, the count of liquid morphine for a resident did not match between the narcotic count sheet and the MAR, with missing doses and unexplained reductions in the amount of medication. An empty morphine bottle was found in the trash, which was against facility policy, and the bottle was not retrieved for investigation. Additionally, there were instances where medication was signed out at times when the nurse was not present in the building, and doses were documented on the narcotic sheet but not in the electronic health record. Nursing staff interviews and observations revealed that the process for counting controlled substances was not consistently followed. During shift changes, one nurse would count the medications while the other would only verify the count on the sheet, without actually observing the physical count or verifying the accuracy of the documentation. Some nurses admitted to not following the correct procedure and not reporting discrepancies or potential drug diversion. There was also confusion and errors in documenting the administration and remaining quantities of morphine, with some nurses unable to explain the discrepancies or the process errors that occurred. The resident involved had significant medical needs, including severe cognitive impairment, chronic pain, and was on hospice care for advanced cancer. The resident's pain management was compromised due to the medication discrepancies, and she reported increased pain after her liquid morphine was discontinued and replaced with other pain medications. The facility's documentation and handling of controlled substances did not comply with policy requirements, and the lack of accurate record-keeping and oversight led to unaccounted doses of narcotics and potential delays in pain management for the resident.