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Springfield Medical Center
We were unable to account for 69 Percocet® tablets, 43 Tylenol® with Codeine tablets, 43 Ativan® 1 mg tablets, 2 Codeine 30 mg tablets, 2 Phenobarbital 30 mg tablets, and 4 Duragesic® 75 mg patches. The 69 Percocet tablets were related to 39 errors on the substock Proof of Use sheets that could not be resolved using the inmates' MARs. These errors include:
- Twenty transactions that showed a decrease in the balance column, for which a corresponding amount administered was not recorded in the usage column, for a difference of 38 tablets; and
- Nineteen transactions recorded in the usage column that did not match the change in the balance column, for a difference of 31 tablets.
The 43 missing Tylenol® with Codeine tablets were related to 19 errors on the substock Proof of Use sheets that could not be reconciled with the inmates' MARs. These errors include:
- Eleven transactions that showed a decrease in the balance column, for which a corresponding amount administered was not recorded in the usage column, for a difference of 22 tablets;
- Seven transactions recorded in the usage column that did not match the change in the balance column, for a difference of 19 tablets; and
- One transaction of a return to substock that was not added to the inventory balance, for a difference of 2 tablets.
For the 43 missing Ativan® tablets, we found:
- The mainstock records showed a transfer out of 140 tablets to the substock, in January 2005. However, the corresponding substock records only showed a transfer in of 122 doses, resulting in 18 unaccounted for tablets;
- Two decreases in the substock inventory that could not be accounted for with an inmate's MAR, for a difference of 11 tablets;
- The mainstock records showed 1 transfer out of 10 tablets to the substock in December 2004. We were unable to account for the medication being transferred in on the corresponding substock records, resulting in 10 unaccounted for tablets; and
- Three transactions recorded in the usage column did not match the change in the balance column, for a difference of 4 tablets.
The remaining 8 missing controlled substances (2 Codeine 30 mg tablets, 2 Phenobarbital 30 mg tablets, and 4 Duragesic® 75 mg patches) resulted from several transactions errors.
La Tuna FCI
We were unable to account for 60 Tylenol® with Codeine tablets, 35 Klonopin® tablets, 3 Valium® vials, and 1.5 milliliters of liquid Andro®.
- For the 60 missing Tylenol® with Codeine tablets, the mainstock records showed transfers out totaling 122 tablets to the camp between June and August 2004. The corresponding substock records at the camp, however, only showed total transfers in of 62 tablets, resulting in 60 unaccounted for tablets.
- For the 35 missing Klonopin®, we found the institution received a total of 58 tablets that were transferred to the facility with an inmate. Using the inmate's MAR, we were able to determine that 23 of the 58 tablets were administered to the inmate during June and July 2004. However, we were unable to account for the remaining 35 tablets. In addition, we noted that the Klonopin® tablets were not recorded as part of the institution's quarterly controlled substances inventory.
- For the three missing Valium® , we found the substock records at the Federal Satellite Location in El Paso, Texas, showed a transfer out of three vials to La Tuna FCI in March 2004. However, La Tuna FCI did not have a record of receiving the medication, resulting in three unaccounted for vials.
Atwater USP
We were unable to account for 46 Lomotil® tablets and 39 doses of Liquid Tylenol® with Codeine Elixir.
- The mainstock records showed 3 transfers of 100 tablets to one inmate between January and February 2005. We examined the inmate's corresponding MAR and were able to verify the administration of 254 tablets, leaving 46 unaccounted tablets. We noted that the 300 tablets were not recorded in the substock.
For the 39 missing Liquid Tylenol® with Codeine Elixir:
- The mainstock records showed 3 transfers of 10 doses each to the OmniCell between September and December 2004. We reviewed the OmniCell records and were unable to account for the medication being transferred, resulting in 30 unaccounted-for doses;
- The mainstock record showed a transfer out of 20 doses to the OmniCell in February 2005. However, the corresponding OmniCell records only showed a transfer in of 12 doses, resulting in 8 unaccounted-for doses; and
- The mainstock records showed a transfer out of 10 doses to the substock, in August 2004. However, the corresponding substock records only showed a transfer in of 9 doses, resulting in 1 unaccounted-for dose.
Initially, our tests were unable to account for 1,391 controlled substances. Subsequent to our review, the staff at USP Atwater provided additional documents showing the existence of a second substock that we were not aware of during our initial visit. The additional information helped to account for the majority of missing controlled substances. Nevertheless, we were still unable to account for the 46 Lomotil® tablets and the 39 doses of Liquid Tylenol® with Codeine Elixir.
Danbury FCI
We were unable to account for 19 Phenobarbital tablets, 4 Tylenol® with Codeine tablets, and 1 milliliter of liquid Stadol®. These missing drugs were related to decreases in the balance column on the substock Proof of Use sheets, for which no amount was recorded in the corresponding usage column. On each occasion, the substock records identified the inmate's name and number; however, we were unable to verify the administration of the tablets using the inmate's MAR.
Forrest City FCI (Low)
We were unable to account for 10 Tylenol® with Codeine tablets and 1 Phenobarbital tablet. For the 10 missing Tylenol® with Codeine, the mainstock records show a transfer out of 10 tablets to the medium security facility in September 2004. We were unable to account for the medication as being transferred in, on the corresponding records for the Forrest City FCI medium security facility. For the missing Phenobarbital tablet, the mainstock records show a transfer out of 30 tablets to the camp in October 2004, and a return transfer of 29 tablets from the camp on December 2004, resulting in 1 unaccounted for tablet. The camp did not maintain records showing either transfer or that the missing tablet was given to an inmate.
All Other Institutions
At the remaining seven institutions, controlled substances were generally accounted for; however, we found some minor issues at the following five institutions:
- Oklahoma FTC – We were unable to account for four Percocet® tablets, and one Phenobarbital tablet because errors in the usage column of the substock Proof of Use sheet could not be resolved using the inmates' MARs.
- Atlanta USP – We were unable to account for two Percocet® tablets, and two Klonopin® tablets because errors in the usage column of the substock Proof of Use sheet could not be resolved using the inmates' MARs.
- Florence USP – We were unable to account for three Phenobarbital tablets and one Lomotil® tablet because errors in the usage column of the substock Proof of Use sheet could not be resolved using the inmates' MARs.
- Florence FCI – We were unable to account for two Percocet® tablets, one Morphine tablet, and one Valium® injectable because errors in the usage column of the substock Proof of Use sheet could not be resolved using the inmates' MARs, and discrepancies in the disposals reported by the institution and the returns company.
- Alderson FPC – We were unable to account for two Tylenol® with Codeine tablets and a quarter tablet of Klonopin® 1 mg because errors in the usage column of the substock Proof of Use sheet could not be resolved using the inmates' MARs.
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