F0755

D

Failure to Obtain Required Dual Witness Signatures for Wasted Narcotic Medication

Wagoner, Oklahoma Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to follow its Discarding and Destroying Medications policy requiring the signatures of at least two witnesses when wasting narcotic medications. Record review showed that a resident admitted on 08/20/24, with diagnoses including emphysema and heart failure, had a physician’s order dated 12/06/25 for oxycodone 10 mg by mouth every six hours. On the Controlled Drug Receipt/Record/Disposition Form for February 2026, an entry dated 02/13/26 at 6:00 a.m. documented that one 10 mg oxycodone tablet was wasted, but the form contained only one signature instead of the required two. During interviews, an LPN stated that when a narcotic medication is wasted a nurse must witness and sign off with the other employee, and the infection preventionist confirmed that two staff members are required to sign when a narcotic is wasted, demonstrating that the documented practice for this resident did not comply with facility policy.

The infection preventionist identified that 48 residents in the facility received medications, indicating that the deficient practice occurred in a setting where multiple residents were receiving pharmaceutical services, although the documented failure to obtain two signatures for narcotic wasting was specifically identified for one resident receiving oxycodone.