Unsecured Oxycodone Blister Pack Left Unattended in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a controlled substance was properly secured and under direct supervision of nursing staff, in accordance with facility policy and professional standards. Facility policies on medication storage required that medications and biologicals be stored safely, securely, and properly, and that DEA schedule II–V controlled substances be stored in a permanently affixed, double-locked compartment separate from other medications. Despite these policies, a blister pack card containing oxycodone 5 mg tablets, a controlled substance, was removed from secure storage and left unattended in a resident’s room, after which it could not be located. The resident involved had been admitted with significant medical conditions including complete C1–C4 quadriplegia, muscle weakness, neuropathic bladder, seizures, and atrial fibrillation, and had a physician’s order for oxycodone 5 mg, two tablets (10 mg) by mouth every four hours PRN for severe pain. On the evening in question, the resident complained of overall body pain and requested oxycodone, specifically wanting assurance that the correct medication and dose would be given. In response, the assigned nurse unlocked the narcotic drawer, removed the entire blister pack card of oxycodone, and brought the whole card, along with a medication cup and water, into the resident’s room. She showed the resident the card, dispensed two tablets into the cup, and placed the blister pack card on the bedside table, leaving 34 tablets remaining. After administering the medication and leaving the room, the nurse later noticed that the oxycodone card was not in the narcotic drawer and informed another nurse. Both nurses searched the narcotic drawer and the entire medication cart without finding the card. The nurse then realized she had left the card in the resident’s room and returned to look for it, but it was no longer on the bedside table. The resident denied seeing the oxycodone card. The narcotic log documented that at 19:20 the amount on hand was 36 tablets, two were used, and 34 remained, consistent with the nurse’s account. Video footage reviewed by the DON showed the nurse entering the resident’s room with a medication card and exiting without it. The DON confirmed that it was not typical or best practice for nurses to bring an entire medication card into a resident’s room and stated that medications should be prepared at the cart and not left unattended at the bedside.
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