tracking narcotics

[TLDey]

Hi, I've been working on a private duty case for the past several months. There are several nurses in the home. When I first started on the case, the nurse I took over for full-time, an LPN, advanced to become the clinical nursing supervisor for the agency. (She still staffs in the patient's home one day per week, and designates herself as the "Casemanager" and the "only one qualified" to direct the patient's care, in addition to her new supervisory duties with the company). This nurse asked me to take over the monthly med ordering when I first started. The patient was on Ativan and Percodan at that time, and they were keeping big bottles (up to #120 count) in a non-locked, fully-accessible-to staff-and-family, and non-counted backup cabinet. We used the backup meds to restock smaller (#25 count) bottles which were kept in the main med cabinet. These bottles we counted every shift, keeping a sign-out sheet for them. (The sign-out sheets get turned into the company, where they are filed in the patient's medical record; no one tracks anything from them).

I asked her why we weren't counting the big bottles in the backup cabinet, and she said it was because it would take too long, and there'd "never been a problem" (how she knew that, I don't know). I've been an RN for 26 years, including 14 in the Emergency Department, and I've had several coworkers get mandated to treatment for addictions and diverting meds, so I was leery, but I went along with what she said. The patient had been with the company 6 months, by then.

After I was 6 months into the case (so the patient had been with the company for a year, without having her backup meds counted) , the doctor started ordering larger refills (#180 count) of the back-up Ativan. We had d/c'd the patient's Percodan because of med reactions, and I signed over the remaining Percodans to the patient's spouse, so we wouldn't be responsible for them. The doctor ordered (#180 count) bottles of Ultrams instead. The nursing supervisor, still working the home, said we didn't need to count the Ultrams, giving the reason that "it's not addictive, they count it in nursing homes, but we don't need to count it in home care". (I don't know what resource she was quoting).

I started to feel funny about not counting the backup Ativan, and not counting the Ultrams at all. So I personally started counting them both, whenever I was working. I found 3 Ativan tablets missing within a 2 week time period. (At the same time I discovered this, one of the nurses, admitted to me just before she quit, that she was doubling up the patient's ordered phenergan dose occasionally, and occasionally giving 1-1/2 times the ordered Ultram dose, as we weren't counting these, so she likely had been doing this with the Ativans also).

I let the clinical nursing supervisor know about the discrepancy, and I told her I initiated sign-out sheets for both big and small bottles of Ativan's and Ultrams. This was just two weeks ago.

This supervisor has since staffed in the home two shifts, and while most of the rest of us have been counting the backup pills and signing the narc sheets, she herself has NOT been counting them, and she also has NOT communicated anything to the staff regarding counting pills. Now I'm wondering if maybe SHE is having a problem. She has access to other patient's homes/meds, with her supervisory visits, and it doesn't look like she's interested in changing the counting policy! How could a nursing supervisor of an agency, after having been reported a problem, not be interested in an effective resolution to the problem?

Would like suggestions please, as to how to proceed, or a written resource that might impact company policy for counting controlled substances. The easiest thing I could do for this case would be to ask her to have the doctor write for only small refills so we don't have a backup supply to count, or to see if we could get them bubble-packed, but it wouldn't satisfy my need for investigating this nursing supervisor.

Thank you, Terry, RN

[caliotter3]

I had a nice long paragraph typed up and when I attempted to post it, the post got lost in the internet. How fascinating. Let's see what happens this time. Short and sweet, either you go above her to complain to the nursing Director or the business manager of the agency, or you institute your idea to have the doctor fill the prescription for a small bottle at a time and keep the sign in sheet going for that small bottle. Get the stock bottles out of the equation. From experience, I have found that home health agencies do not care to deal with issues involving the accountability of controlled substances.

[nursel56]

I agree with Cali, the agencies tend to be very lax in the homes. Part of the problem we would run into is that not all patients have skilled nursing 24/7, the caregivers (some who don't speak English) would give the med on their shift and not write anything down, or the patient wouldn't remember. Then you are dealing with a discrepancy that doesn't have the normal procedures to track down as you would in a larger facility.

I have not heard of such large amounts of narcotics kept unsecured in a "back-up" cabinet. Maybe our state laws differ, but I've had more difficulties with providers not wanting to renew narcotics when the patient really needs them - oxycodone especially due to their fears of being investigated.

Obviously, counting the small bottles without counting the large one is pointless. The supervisor there not wanting to follow through with the fix is very curious, and merits going to her manager if she continues to be uncooperative. I'll be interested in hearing how this will be addressed with the agency.

[TLDey]

Thank you for your support! Yes, there's two staff present (a nurse and an aide) 24/7. I did address it with the Business Manager for the agency (whose daughter actually owns the company), and she assured me she'd hold the "managing" nurse accountable to count the controlled substances just as the rest of us were doing. The Business Manager offered to put a lockbox in the home if needed. The managing nurse spoke with the patient's husband, who preferred to hold onto the backup meds himself (keeping them on a different level of the home that we don't have access to), vs. resorting to a lock-box, and she also made arrangement with him, that when she worked once a week, he would give her enough to refill the small bottles to get us through the week.

I felt like this was a satisfactory solution, and no longer feel the need to investigate whether she's diverting meds or not, as long as the rest of us are above question. I didn't mean to make it sound like an "RN vs. LPN" issue, but this girl's been a bully and a thorn in my side, and I suppose it made me feel a little better to throw some credentials around, tho' I'm not so proud of it now.

[caliotter3]

Kind of funny how each case seems to attract at least one "Queen Bee" nurse. Glad this is resolved, making things a tad more safe for the nurses working the case.

[Butterfliesnroses]

As a side note, no nursing home I've every worked for has ever counted Ultram.