Failure to Secure and Account for Controlled Substances Resulting in Missing Narcotics
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled, resulting in missing hydrocodone-acetaminophen tablets for one resident. The resident was an older adult with obstructive hydrocephalus, malignant neoplasm of the brain, dementia, and significant functional dependence, including being rarely or never understood and dependent on staff for bed mobility, transfers, and toileting. The resident had a care plan for pain that included monitoring and documenting for side effects of pain medication, and an active physician order for hydrocodone-acetaminophen 5-325 mg, one tablet twice daily for pain related to brain cancer. After the resident expired in the facility, 43 remaining tablets of hydrocodone-acetaminophen 5-325 mg were turned over to the ADON. According to the provider investigation report and staff interviews, the ADON logged these tablets on the drug destruction log, paired the count sheet with the medication using a rubber band, and placed them in a locked closet in her office rather than in the safe located inside that closet. At that time, nurses brought discontinued narcotic medications to the ADON, who logged them and placed them in the closet, not in the safe. The ADON reported she had been trained to store the medications in the closet, and acknowledged that her office door could be bumped open and that staff accessed her office refrigerator and bathroom at all hours when she was not present. When the pharmacist and DON later pulled medications for destruction, the hydrocodone-acetaminophen tablets for this resident, although listed on the destruction log, were not found in the closet or lock box. Interviews with the DON and administrator confirmed that at the time of the incident, the ADON office door could be opened by bumping it with a hip and the closet door lock could be easily bypassed with a butter knife. They also confirmed that the narcotic medications awaiting destruction were not stored in the safe and that staff were allowed access to the ADON office, and the facility did not review camera footage to identify who might have taken the narcotics. The facility’s own policies required that only authorized personnel have access to controlled drugs, that controlled substances be stored in a locked container separate from non-controlled medications, and that unused controlled substances be retained in a securely locked area with restricted access until disposal, which was not followed in this case.
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