Failure to Maintain Controlled Drug Accountability Records for Hydrocodone-Acetaminophen
Penalty
Summary
The deficiency involves the facility’s failure to maintain required records for a controlled substance prescribed to a resident. Facility policy required that upon receipt of controlled medications from the pharmacy, both the pharmacy and a licensed nurse sign controlled administration sheets, and that all controlled medications be accounted for each shift by oncoming and outgoing nurses using controlled administration sheets stored in a narcotic binder on each medication cart. The facility also had a HIPAA documentation policy requiring secure maintenance and availability of required documentation for audits and investigations. A resident with rheumatoid arthritis, chronic pain, and severe cognitive impairment (BIMS score of 1) had physician orders for hydrocodone-acetaminophen 7.5-325 mg, initially as a PRN dose for breakthrough pain and later scheduled every eight hours for pain. The MAR for December showed the PRN dose was not given, while the scheduled dose was administered three times daily except for five doses when the resident was out of the facility. When the surveyor requested the resident’s controlled drug receipt/record/disposition forms for hydrocodone-acetaminophen, the DON produced forms dated for multiple prior dispensing dates, each showing pharmacy delivery of 30 tablets, but was unable to provide the controlled drug forms for the month of December. During interviews, the DON confirmed that she did not have the December controlled drug forms and stated she was unable to reconcile the resident’s hydrocodone-acetaminophen for December without those records. As a result, the facility did not have a complete system of records of receipt and disposition of this controlled drug and could not account for all doses administered or dispensed during that month, contrary to its own policies and regulatory requirements for controlled drug accountability.
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