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Preventing Diversion of Controlled Substances in Long Term Care Facilities

by Beth Greenway, RN

Let’s face it, diversion of controlled substances is more common than we think but is usually kept quiet in facilities.  Diversion leads to serious patient safety, harm to the healthcare worker and liability to the facility.

There are three main components to aid in the management of controlled substances in a long-term care facility.  Chain of custody of the medication is vital.  When controlled substances are delivered to the facility, nurse should sign off on receipt of the medication including the actual amount received.  These medications should then be, immediately placed on the appropriate med cart and under double lock per regulation. Placing the medication in the med room versus under double lock, does not constitute a viable chain of custody.  With new regulations regarding PRN controlled substances, nurses should be aware of expiration date and remove medication from cart.  Two nurses should sign that the medication has been removed from the cart.  The med should then be given to the designated staff member appointed by the DON that is responsible for storing controlled substances for the facility. This designated staff member should be the only person with access to storage to prevent diversion.

A surveillance system should be in place in every facility to account for every step of the controlled substance entering the facility to when it is either discontinued, expired or the resident passes away.  Nursing facilities should employ self-audits, assigned to the appropriate staff member.  This would include the date medication is delivered, actual prescription, narcotic count sheet balance and shift change showing that the count is correct.

Storage and security of controlled substances requires facility regulations, physical access and controlled counts.  Nurses should always question any controlled substance that has been “taped” back into a punch card to ensure that it actually is the correct medication.  That medication should then be witnessed and wasted per regulation.  Any medication that requires a count should never be placed back into the original container. When a controlled drug is “punched” for administration by a nurse and either refused by patient or dropped, this medication must be witnessed and wasted.

Healthcare facilities should develop diversion prevention strategies in order to protect their resident’s, healthcare workers and facility from avoidable liability.