Narcs sent home with wrong resident

[laderalis]

I work in a LTC facility that also does rehab. Recently I noticed that a fellow nurse had sent three cards of Norco home with the wrong resident.

Our narcs are kept in a locked drawer in our med cart. The nurse sent four cards home, the first card belonged to that resident, the next three belonged to another resident.

I notified this nurse personally, to let her handle it. I did not want to make her feel that I was trying to get her in trouble. I wanted her to be able to notify the DON herself. She was shocked and She said she would notify the DON. (If she doesn't, I will notify the DON myself)

What is your facilities policy on this? The other two nurses I spoke to had never seen this happen before.

[BrandonLPN, LPN]

I never liked setting up meds for residents to take with them. Isn't that dispensing medication? Which is technically out of our scope of practice?

[blessedmomma247]

I would check with your policy just to be sure. I know in most LTCs, all meds go home with a resident, EXCEPT the narcs. The MD must give a script for those.

[laderalis]

We only send home narcs and opened items, like inhalers, insulin vials etc because we can't send them back to pharmacy for the resident to get credit. All other meds go back to pharmacy and the resident gets a credit for the unused med.

These were three whole blister packs, full packs, (90 pills) that were sent home with the wrong resident.

[blessedmomma247]

Yes...we would do the same...anything opened would go with the resident and all blister packs (except Narcs). UNLESS they were medicare residents...then only opened meds would go home with them. The other blister backs would go back to pharmacy for credit.

Can you call the family and maybe they could bring them back? I really dont know what to do in that situation. DON is gonna have to sign off to approve the pharmacy to refill it...at the faciltiy's cost.

[laderalis]

My question is about sending a controlled substance home with the wrong person! We send home narcs often, just not to the wrong person.

At the minimum it's a HIPAA violation!

[ChristineN, BSN, RN]

My question is about sending a controlled substance home with the wrong person! We send home narcs often, just not to the wrong person.

At the minimum it's a HIPAA violation!

How is it violating HIPAA? Assuming the meds aren't labeled I don't see how this would violate HIPAA. A med error, though, definitely

[SquishyRN, BSN, RN]

How is it violating HIPAA? Assuming the meds aren't labeled I don't see how this would violate HIPAA. A med error, though, definitely

In LTC each blister pack is labeled with the patient's info, which includes name and medical record number. So, yes, this would also be a HIPAA violation, among many other things...

[CapeCodMermaid, RN]

You can't fix stupid. It's basic nursing to read the med labels before you give a medication so, of course, the meds being sent home should have been checked before they were given out.

[Havin' A Party!, ASN, RN]

Yikes! This is a horror story.

Any efforts being made to retrieve the narcs?

[laderalis]

Two of the three cards were brought back but I don't know exactly how and I don't know what was said.

Assuming the DON called and they were retrieved by an employee.

I don't know if the nurse that signed for them was disciplined.