Failure to Prevent and Detect Diversion of Hydrocodone for Multiple Residents
Penalty
Summary
The facility failed to implement its Drug Diversion policy and procedure to ensure secure storage, accurate documentation, proper administration, monitoring, and accountability of narcotic controlled substances for three residents. During an interview and record review with the Administrator, it was determined that one nurse discovered a missing hydrocodone 10/325 mg bubble-pack containing 28 pills for one resident, along with the corresponding inventory sheet, when starting an evening shift. The Administrator stated that the nurse knew this hydrocodone bubble-pack should have been present because he had administered from it two days earlier. Following this discovery, the facility expanded its search and found that two additional residents each had a missing hydrocodone 5/325 mg bubble-pack of 28 pills, also with missing inventory sheets, and that three more hydrocodone 10/325 mg bubble-packs for the first resident were missing with their inventory sheets. The Administrator reported that the missing inventory sheets were the main reason the hydrocodone losses were not detected for the three residents, because the narcotic count appeared to be correct in the absence of those records. The Administrator also stated that copies of the inventory sheets for resident narcotics are not taken when medications are delivered, which contributed to the inability to track when the narcotics were received and subsequently went missing. A facility five-day report indicated that a total of 164 hydrocodone pills were diverted. The facility’s written Drug Diversion policy states that the facility maintains zero tolerance for narcotic drug diversion and requires secure storage, accurate documentation, and immediate documentation of all narcotic administrations in the MAR and Controlled Substance Record, but these requirements were not effectively carried out in practice for the affected residents.
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