Failure to Reconcile Overflow Narcotics Resulting in Missing Hydrocodone
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper narcotic reconciliation, including regular counts of all controlled substances and those stored as overflow, which resulted in missing hydrocodone tablets for a resident. The facility reported that staff discovered 12 hydrocodone tablets were missing after a discrepancy was identified between the documented count and the actual number of pills in the bottle. The narcotic dispensing record for the resident’s hydrocodone showed that a count of 30 tablets had been crossed out and changed to 18, with the change initialed by two individuals and dated and timed, followed by documentation that one tablet was administered, leaving a remaining count of 17. According to witness statements, a CMA requested assistance from an LN to obtain hydrocodone from the overflow cabinet to refill the medication cart. When they counted the pills in the overflow bottle, they found only 18 tablets, while the narcotic count sheet indicated 30. The LN then corrected the count on the sheet from 30 to 18 without immediately notifying administration of the discrepancy, and the CMA also delayed reporting the error until the following day. The facility’s investigation determined that when the hydrocodone was originally picked up from a third-party pharmacy and placed in the overflow cabinet, the LN who secured the medication created a narcotic count sheet but did not count the contents of the bottle at that time. The investigation further documented that the hydrocodone bottle was not recounted between the initial correct count performed later that same day by two LNs and the subsequent count several days later when the 12 missing tablets were discovered. During this period, no additional counts of the overflow narcotics were performed, and the discrepancy was only identified when staff attempted to move the medication from overflow storage to the medication cart. The facility’s failure to consistently perform and reconcile narcotic counts, including for overflow medications, and the delay in reporting the discrepancy by involved staff, led to the identification of missing hydrocodone tablets for the resident.
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