Failure to Account for and Return Controlled Oxycodone Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective systems for the return, disposition, and accurate accounting of a resident’s controlled medication, specifically oxycodone 5 mg prescribed PRN for pain. The resident was admitted with an order for oxycodone 5 mg every 6 hours as needed and received a total of four doses in March and one dose in April, after which no further administrations were documented. The controlled substance count record showed that seven oxycodone tablets remained after the last documented dose on April 1, and the resident was discharged the following day with those seven tablets still on hand. On April 7, a Controlled Substance Prescription Returned to Pharmacy form was completed indicating that the seven remaining oxycodone tablets were being returned to the pharmacy in a sealed Controlled Medication Return Bag. Nurse #1 reported that he prepared the resident’s oxycodone for return and took the return form to Nurse #2 for signature without bringing the narcotic cards for verification. He acknowledged leaving the medication unattended in the medication room while obtaining the second nurse’s signature and stated that Nurse #2 did not participate in verifying the medications. Nurse #1 then placed the narcotic cards, including the card with seven oxycodone tablets, into the return bag, sealed it himself, and stored it in the locked narcotic drawer. Nurse #2 confirmed she signed the form without verifying the medications or having access to them and later recognized she should not have signed without confirming the contents. On April 8, Nurse #3 and the pharmacy driver signed the pharmacy pick-up slip, verifying only that the serial number on the sealed Controlled Medication Return Bag matched the serial number on the pick-up ticket. Nurse #3 stated she did not verify the contents of the sealed bag at the time of pick-up. The Pharmacist in Charge explained that the pharmacy’s process required matching the bag’s serial number to the pick-up ticket and checking that the seal was intact, but did not require verification of the bag’s contents by the driver. When the pharmacy processed the return on April 9, the pharmacy’s copy of the Controlled Substance Prescription Returned to Pharmacy form included a handwritten note stating that the medication was not in the bag and that the pharmacy had called the facility twice about the issue. The Pharmacist in Charge confirmed that the seven oxycodone tablets never arrived at the pharmacy and stated that the facility remained responsible for following up on the missing medication. Interviews with the ADON, DON, and Administrator confirmed that the missing oxycodone tablets were never found and that the facility’s process at the time relied on serial number verification rather than verification of the actual controlled substances being returned.
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