Failure to Maintain Accurate Controlled Drug Accountability Resulting in Narcotic Diversion
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system for reconciliation and accountability of controlled medications on all four nursing units, which resulted in diversion of at least 60 hydrocodone-acetaminophen (Norco) tablets from one unit. A facility reported incident documented that two cards of a resident’s hydrocodone-acetaminophen, totaling 60 tablets, were discovered missing from the medication cart. A pharmacy packing slip showed that four cards (120 tablets) of hydrocodone-acetaminophen had been received for this resident and signed for by an RN. A progress note recorded that the resident was found unresponsive at 6:00 a.m., CPR was initiated but unsuccessful, and the resident was pronounced dead at 6:15 a.m. Staff statements and records revealed discrepancies and irregularities in the narcotic count process. One LPN reported last seeing the resident’s hydrocodone-acetaminophen at the end of her shift and, upon returning to work, noted that two cards were missing even though the narcotic count was documented as correct. A narcotic count sheet for the same medication was later signed as having 45 tablets nearly three weeks after the resident’s death. Review of Shift Change/Controlled Substance Inventory Tracker sheets from all six medication carts across the four units showed that two nurses had not consistently signed as required when controlled medication cards and count sheets were added or removed, contrary to the instructions on the forms and facility policy. Further investigation identified that a page was missing from the narcotic count book, which was numbered sequentially, and that a new count page had been started. An LPN who had worked the evening shift before the discrepancy reported that narcotic counts between evening and night shift had been correct, but the night shift nurse only had the new narcotic sheet to reference and was unaware that cards were missing. Another nurse questioned the reduced number of medication cards the following morning. The LPN involved denied that extra cards had been present in the cart but later admitted to starting a new narcotic count sheet, claiming the original sheet was already missing and that the new count was based solely on the medications present in the cart. The facility’s own policies required double-locked storage, accurate shift-to-shift counts by two nurses, proper documentation of controlled drug cards and count sheets, immediate reporting and investigation of discrepancies, and timely removal and destruction of controlled substances after discharge or death, but these procedures were not followed, contributing to the diversion and inaccurate accounting of controlled medications.
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