Following an investigation into the security and access to Schedule 4 and Schedule 8 drugs at Beaumont Care Aged Care Services ('Beaumont Care'), the Office of the Health Ombudsman (Queensland) ('Ombudsman') found the aged care provider had remedied deficiencies in their medication management system that had been exploited by a former drug-addicted employee.
Initiating complaint
On 28 October 2014, the Ombudsman was contacted by an unregistered provider who claimed to have formerly worked at the Kippa-Ring and Redcliffe facilities of Beaumont Care. The unregistered provider advised they had stolen schedule 8 drugs (Endone, Ordine) and schedule 4 drugs (Temazepam, Oxazepam, Diazepam) from the drug safe and the drug room which they were able to access. The drugs were also obtained from the leftover drugs of patients who had died in order to fuel the unregistered provider's drug addiction.
Investigation
The Ombudsman commenced an investigation at both facilities into the issues raised by the unregistered provider on 12 November 2014. When notified of the investigation, Beaumont Care acknowledged they had conducted two internal investigations into missing controlled drugs during the relevant time period, although the culprit had not been definitively identified. Beaumont Care provided the Ombudsman with documentation of their policies which included a medication management policy, medication framework document, medication administration competency checklist and audit documents.
The Ombudsman assessed the system for management of medications with three issues in mind:
- Whether adequate policies, procedures and protocols were in place
The Ombudsman noted internal investigations undertaken by Beaumont Care following the incidences identified and remedied a number of contributing factors to the thefts, including:
- The keys to the controlled drug safe had been given to an unregistered provider on one occasion;
- The keypad to the safe had four worn numbers on it, clearly identifying the four numbers regularly used in the pin; and
- The door to the medication room was damaged such that the lock would not catch properly.
The evidence indicated that the unregistered provider exploited these deficiencies in the system to gain access to the medication room and controlled drug safe to misappropriate the medications.
Beaumont Care then implemented corrective measures which included changing the pin code regularly, having the safe changed to a key lock safe and fixing the broken door to the medication room. These actions in conjunction with the existing governance processes were considered sufficient to mitigate the risks of the events recurring.
- Whether staff were compliant with the policies, procedures and protocols
Based upon the evidence at hand, the Ombudsman concluded there was no widespread training issue or disregard by staff for policies, procedures and protocols. Non-compliance by one staff member, believed to be the initial complainant, had been the subject of investigation by Beaumont Care and was adequately addressed prior to that employee's resignation.
- Whether systematic improvements should be implemented
The Ombudsman considered the corrective actions taken by Beaumont Care to ensure adequate security of the medication room to be an appropriate response to mitigate the risk of reoccurrence. Notably, Beaumont Care had undergone an Australian Aged Quality Agency audit which reported full compliance.
Conclusion
Based upon the above grounds, the Ombudsman formed the view that no further action be taken under section 33(1)(a)(iv) of the Health Ombudsman Act 2013 (Qld) as the identified issues were resolved or appropriately finalised.
Having medication management policies in place will not prevent an opportunist from taking advantage of lapses within security regimes. The Beaumont Care example is a reminder to all health care providers to regularly audit and review the policies in place and to assess for potential gaps in security.
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