The Emergency Kit, the Balance, and the Deceased Resident
You are the consultant pharmacist for a 120-bed skilled nursing facility and the closed-door pharmacy that serves it. On your monthly visit you find: (a) the emergency drug kit seal is broken and four morphine 10 mg tablets are missing - the night nurse says she gave them at 02:00 for new severe pain and "the order got written the next morning"; (b) resident 214's oxycodone 5 mg prescription was written for #60 with instructions to dispense 30 and supply the balance later; the pharmacy sent 30 on June 1, and the resident was discharged to home on July 12; (c) 18 unit-dose lorazepam 0.5 mg tablets belonging to a resident who died on July 3 are still in the medication room. The director of nursing wants to know what to do with the morphine, the oxycodone balance, and the lorazepam, and who signs what.
1. Reconstruct what happened with the emergency kit morphine and state what must be documented and reported.
Read the worked answer
Emergency kit rules first. Drugs in a facility emergency kit may be removed only pursuant to a valid order (or an approved emergency-kit protocol that requires a prescriber order to follow promptly). A dose given at 02:00 with the order written "the next morning" is a documentation failure at minimum and diversion at worst - and a Schedule II drug is the worst possible item for it.
Reconstruct: pull the E-kit log, the MAR/eMAR, the nurse's notes, and the prescriber's order with its time stamp. Interview the nurse and the supervisor separately. Count the kit against the log.
If the drug was administered and an order now exists with a truthful time: annotate the record, obtain the prescriber's dated order with the original administration time, correct the MAR, and document the protocol deviation.
If it cannot be accounted for: treat it as a loss. Notify the PIC, the administrator, and the prescriber; file a DEA Form 106 for theft or significant loss and notify Connecticut DCP's Drug Control Division promptly per its rules. Do not "replace it from stock and forget it" - an unaccounted Schedule II tablet in a facility is a reportable event, and the pharmacist is often the only person positioned to catch it.
Then: reseal with a new tamper-evident seal, restock to the approved list, log the reseal, and report to the medication safety/QAPI committee.
2. Was the partial fill of the oxycodone lawful, and what happens to the undispensed balance now that the resident is discharged?
Read the worked answer
The partial fill itself was lawful. A Schedule II prescription may be partially filled at the patient's request or when the pharmacy cannot supply the full quantity, and for a long-term care facility resident or a terminally ill patient the remaining portion may be dispensed within 60 days of the date the prescription was written (CARA, 2016). The quantity dispensed and the date must be documented on the prescription. June 1 + 60 days = July 31, so the balance was still dispensable in the abstract.
But the patient is gone. A prescription belongs to a patient. Once resident 214 was discharged to home on July 12, that prescription can no longer be dispensed to the facility for that resident, and it absolutely cannot be dispensed to a different resident. The remaining 30 tablets are not available stock and must not be repurposed.
What to do:
- Notify the prescriber that the resident has been discharged and cancel the balance.
- Void the balance in the pharmacy system with a dated note (discharge date, prescriber notified, balance canceled).
- Confirm nothing was delivered after the discharge date. If product was already delivered to the facility, treat it as the destruction scenario in the next question.
- Note in the consultant record as a policy gap: the pharmacy needs a discharge notification feed so balances are canceled on the day of discharge, not at the next monthly visit.
3. How are the 18 lorazepam tablets of the deceased resident lawfully disposed of, and what documentation results?
Read the worked answer
They cannot be returned to stock and cannot be given to another patient. They are controlled substances dispensed for a specific person who is now deceased.
Two acceptable pathways (follow the facility's policy and Connecticut's requirements):
- Reverse distributor - transfer the tablets, with a signed, itemized transfer record (drug, strength, quantity, patient name, date, signatures of the facility representative and the receiving registrant).
- On-site destruction - destroy in the presence of the appropriate witnesses (per DEA's 2014 disposal rule for long-term care, a pharmacist and a nurse supervisor or other authorized person), rendered non-retrievable, and documented on a destruction record with signatures, date, drug, strength, quantity, and the method used. If destruction is performed by the registrant, a DEA Form 41 accompanies it.
Also:
- Reconcile against the MAR before destruction - quantities on hand should match doses not administered. A discrepancy is investigated, not destroyed.
- Do not hold these "until the family decides." Set a deadline and follow it.
- Document the witness names and titles legibly; auditors call witnesses.
Consultant pharmacist's role: verify the process happened, not just that a form exists, and raise the pattern (deceased-resident medications accumulating 3+ weeks) with the QAPI committee.