Inadequate Narcotic Sheet Labeling and Accounting for Controlled Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the accounting and documentation of controlled medications for three residents. The facility failed to ensure that narcotic sheets were labeled in a way that accounted for all medications dispensed by the pharmacy, as required for accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. This issue was found during review of the narcotic book on the 2200/2500 hallway medication cart and through interviews with nursing staff. For one male resident with dementia, muscle weakness, spinal stenosis, impaired mobility, gait and balance problems, and potential for uncontrolled pain, the narcotic sheet for APAP/Codeine 300-30 mg was not labeled to accurately reflect all medications dispensed. During observation, an LVN changed the narcotic sheet notation from “card 1 of 2” to “card 2 of 2” to match the numbering on the blister pack, indicating that the original documentation did not correspond to the actual medication card count. The LVN stated that the numbers on the narcotic sheet did not match what was written on the blister pack and acknowledged that this discrepancy affected the ability to accurately track narcotics and determine when to reorder. For a female resident with muscle weakness and wasting, polyneuropathy, cognitive communication deficit, hip fracture, and potential for uncontrolled pain, the narcotic sheet for Tramadol 50 mg lacked any labeling for card count, with no documentation indicating how many cards had been dispensed. Similarly, for another male resident with cognitive communication deficit, pain, muscle weakness and wasting, lack of coordination, hemiplegia/hemiparesis, ADL self-care deficit, limited physical mobility, and potential for uncontrolled pain, the narcotic sheet for APAP/Codeine 300-30 mg also had no labeling for card count. In both cases, the LVN reported that without proper labeling and documentation, staff could not accurately keep track of the narcotics or know when to reorder because the numbers were wrong or missing. The report states that this failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion.
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