Failure to Maintain Accurate Narcotic Count and Prohibition on Pre-Pouring Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate controlled drug record and narcotic count for oxycodone/acetaminophen and allowed pre-pouring of narcotic medications. Resident #9, who had diagnoses including mood disorder, bipolar disorder, anemia, diabetes, mild cognitive impairment, chronic pain, dementia, insomnia, cataracts, absence of a spleen, and follicular disorder, had a physician’s order for oxycodone/acetaminophen 10/325 mg, one tablet four times per day for pain. On review of the Controlled Drug Record-Disposition form for this medication, surveyors found that the record indicated there should have been 13 tablets remaining, but only 12 tablets were present in the medication card in the narcotic drawer. During observation of medication administration, a registered nurse retrieved one oxycodone/acetaminophen tablet for Resident #9 when the card showed 12 tablets remaining, while the controlled drug record still reflected 13 tablets. The record also showed doses signed out in advance for future administration times that were later errored out and initialed by the nurse. In interviews, the nurse first stated she had wasted a dose earlier in the day without a witness or signature, but later admitted she had pre-poured the oxycodone/acetaminophen dose for another resident and stored it in the top drawer of the medication cart. She further stated she had pre-poured and signed out medications for the entire shift and then errored them out when she learned she would be observed for medication administration.
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