Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect three residents from the misappropriation of their controlled medications. One resident, who was cognitively intact and being discharged, had her Hydrocodone-Acetaminophen medication removed from the medication cart by the ADON without proper documentation or following established procedures. The ADON did not count the medication upon removal, did not sign it out, and placed it in a locked drawer in her office instead of the designated discontinued medication storage. The medication count was later found to be off by 10 tablets, and the narcotic log contained three entries with an unrecognizable signature after the last documented administration. During an audit prompted by this incident, the facility discovered that two additional residents had missing discontinued narcotics: one had 120 ml of hydromorphone liquid unaccounted for, and another had 56 tablets of Hydrocodone-Acetaminophen missing. The facility's investigation determined that the ADON was the last in the chain of custody for at least one of the missing medications and had not followed the facility's narcotic policies and procedures. The charge nurse who released the medication to the ADON did so without ensuring proper procedures were followed, despite feeling uncomfortable with the situation. Interviews with staff confirmed that the ADON did not follow the required process for handling discontinued medications, and that the facility's policy required two nurses to sign for narcotics and for discontinued medications to be placed in secure storage. The ADON admitted to removing the medication and not following procedure, but denied taking any of the medication. The facility's review of narcotic logs and interviews with the DON and other nurses corroborated the discrepancies and the failure to adhere to established protocols for controlled substances.