HospitalInspections.org

Based on review of facility documentation and interview, the facility failed to maintain current and accurate records of the receipt and distribution of all scheduled drugs. Facility procedures to trace the movement of scheduled drugs from the point of entry into the facility to the point of disposition were not implemented. Documentation to confirm the quantity of oxycodone hydrochloride (oxycontin), a Schedule II drug, tablets released to Patient #1 at the time of discharge was not maintained. A complaint received by HHSC alleged Patient #1's scheduled, narcotic medication was 'stolen'.

The facility's failure to implement policy to maintain documentation regarding disposition of medications in its custody, to include medications ordered to be returned to the patient upon discharge, failed to minimize the risk for drug diversion.

Findings include:

Review of policy and procedure titled, "Medications Brought in with Patients", annual review 01/2023, documented in part:
"... Controlled substances that are taken into custody will be counted and the quantity noted on the inventory sheet. The patient and staff member receiving medication will sign the form. If the patient/caregiver cannot sign, then a second hospital witness is required... All medication documentation regarding disposition of medications must be clearly marked and maintained for a period of two years."

Review of a Patient's Own Medication, "(POM) - Controlled Drug Administration" record, for Patient #1, indicated the following:
- "oxycontin (oxycodone hyrochloride) 15 milligram extended release tablets, 7 boxes of 20 (sealed) and 1 box of 13 (opened), total quantity of 153" was received by facility nursing staff on 9/12/2023 at 2:00 AM.
- between 9/12/2023 and 9/14/2023, 13 tablets were administered, and "quantity remaining" reflected 140 tablets.
- a notation on 9/14/2023 at 4:20 PM, "discharged" and quantity remaining 140.

Further review of Patient #1's "(POM) - Controlled Drug Administration" record included the following instruction: "Two witnesses must be present to verify count and sign when returning to patient," and "Note: MAINTAIN IN MAR (Medication Administration Record)". The section of the form, including space for documentation of "date', "quantity", "describe in detail", "signature 1", and "signature 2" was blank.

Review of a Progress Note, dated 9/14/2023 at 4:55 PM documented in part: "... All personal belongings including home medications with person at time of discharge..."

During an interview on the afternoon of 11/14/2023, in the facility conference room, Staff #1, Director of Nursing, stated, "... We've asked for a copy (of documents to verify Patient #1's receipt of home medications at time of discharge, including oxycontin) as the police were here. As of today we have not been able to obtain one, and we have not heard anything further from the police or the patient."