Healthcare Compliance Perspective:
Audits must address medication diversion must account for intentional diversion, not only by employees but also residents.
Two residents in a Springfield nursing home were allegedly able to take oxycodone pills from an unsecured narcotic box on the medication cart, and one of them overdosed. That same day a nurse discovered that 23 oxycodone pills were missing, and the facility launched an investigation.
An empty medication sleeve was found in the trash of resident #2, and another resident was noted to be unusually lethargic and both residents were sent to the hospital. It was determined that resident #1 who overdosed had allegedly taken 19 of the pills and resident #2 had taken four pills. Resident #2 was returned to the facility on the same day he was sent, but resident #1 required treatment with Narcan twice and had to remain in the hospital for 19 days.
When he was returned to the hospital, resident #2 admitted that he had distracted the nurse to allow resident #1 to remove the pills from the medication cart’s drawer.
One of the nurses interviewed reported that the drawer of the medication cart did not always close securely; and, although it appeared to be closed and looked like the cart was locked, the drawer could be opened.
The nurse who allegedly failed to securely close the drawer told investigators that she had not been educated about how to operate the medication cart.
The nursing home took these corrective steps after the incident: educated nursing staff on medication security, completed an assessment of both medication carts in the area to ensure they were in working order, initiated medication cart lock audits, educated nursing staff on facility protocol to deal with malfunctioning equipment, changed the keys to medication carts to ensure they were locking securely and implemented monthly preventative maintenance checks on medication carts. The facility also provided a plan of correction to the Ohio Department of Health.
