Failure to Prevent Misappropriation and Ensure Proper Destruction of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ medications from misappropriation and to ensure proper controlled substance handling and documentation. A facility-reported incident described that the former Unit A manager (an RN) removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a second licensed nurse witness the destruction. The RN then left work early without notifying the nurse responsible for that medication cart. When the assigned nurse later attempted to appropriately waste medications from the cart, she discovered the narcotics were already gone. She contacted another RN, who located the Controlled Dangerous Substance Destruction Report on the former unit manager’s desk, bearing signatures and initials of that RN and another staff member. When the other staff member was interviewed, he stated he was only aware of his own medications being wasted and not the additional two narcotics listed on the form. During the survey, narcotic logbooks on Unit A were reviewed and showed multiple days with missing entries (“holes”) in the logs. The current Unit A manager explained that the facility’s process required two licensed nurses to be present for the entire destruction process, from gathering the medications through signing paperwork and destroying the drugs. The DON acknowledged the prior incident involving the former unit manager and stated that the facility’s investigation could not determine which residents’ medications had been destroyed, although she noted that pharmacy could have been contacted using prescription numbers to obtain that information. Review of narcotic logs showed that some medications were documented as sent home with residents and others as destroyed, which the DON said was based on physician orders. When asked, the DON reported that the facility did not go back to verify whether narcotics were actually sent home or destroyed on Unit A during the former unit manager’s tenure and confirmed that the only step taken to determine whether other residents were affected was to verify that all medications were signed off in the records.
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