Failure to Observe Narcotic Medication Protocol and Missing Fentanyl Patches
A physician contacted the facility because he was concerned about the number of prescriptions he was writing, and he was wondering where they were being used. He was particularly curious about some Fentanyl patches he had ordered that had not been placed on the resident for whom they were prescribed.
The facility launched an investigation that included an audit of all prescriptions, and the results of the audit indicated there were no problems. However, because of the concern expressed by the physician regarding Fentanyl patches he had prescribed, the facility checked to determine if the prescription had been filled and if the facility had received it. The staff checked the online record, and it indicated that the patches had been received. When the pharmacy was contacted, they informed the facility that the patches had been delivered to one of the facility’s nurses; so, the pharmacy sent over the form the nurse had signed when the patches were delivered.
Continuing the investigation, the DON examined the narcotic book and noted that at the time of the delivery, two other medications were noted and entered, but the seven Fentanyl 50 mg patches were never entered.d
The same Nurse #1 did the order, sent the fax and received the delivery. When asked about the missing Fentanyl patches, she responded that she never thought twice that she had not signed them in. Nurse #1 normally is at the desk and takes the controlled medication to each nurse when she receives a delivery. Unfortunately, the video cameras were not functioning, so they were not helpful in clarifying the issue. Nurse #1 has been at the facility for 14 years and is well-respected by the physicians.
Nurse #2 is the nurse that Nurse #1 says she gave the medication to. The facility staff looked at the medication book and noted that there were cross-offs and it looked sloppy. Nurse #2 works the night shift and she administers medications after her shift, then waits to count until 8 or 8:30 A.M. She is always very tired, which could be because she is a night nurse. Every time there was a discrepancy in the medication book, Nurse #2 had an explanation for it.
Proper procedure for controlled substances was not followed by either nurse, so both nurses were suspended pending the outcome of the investigation. The police were notified and asked to investigate, then a reportable event notice was sent to the DEA. The facility reviewed the policies and procedures for receiving and dispensing medications, and it was noted that the procedure requires a 2nd nurse’s signature to verify the receipt of a narcotic. In this instance, Nurse #1 was the last one to handle the medication. Nurse #1 signed for the medication when it was delivered, it was in her possession and there was no signature to indicate that she passed it on.
All nurses received training on the facility’s policy and procedure for handling of controlled substances due to the failure to observe narcotic medication protocol.
