Medication Diversion Investigation

Inspection template for investigating suspected medication diversion, including MAR review, witness count verification, staff interviews, and pharmacy follow-up.

Investigation Scope and Case Intake

• Suspected diversion event identified and dated
  Record the date/time the discrepancy or suspicious event was first identified and the medication(s) involved.
• Investigation scope defined
  Select all areas included in the investigation.
• Immediate containment actions completed
  Verify immediate actions were taken to preserve evidence and reduce risk.

Medication Administration Record (MAR) Review

• MAR entries match ordered doses for the review period
  Compare ordered doses, documented administrations, omissions, refusals, and holds for the affected medication(s).
• Late entries, overrides, or unusual documentation patterns identified
  Look for repeated late charting, copied forward notes, unexplained voids, or inconsistent administration times.
• PRN and waste documentation reviewed
  Verify PRN administrations, partial doses, and waste documentation are complete and consistent with policy.
• MAR discrepancies summarized
  Document any missing signatures, unexplained administrations, duplicate entries, or dose variances discovered during review.

Controlled Substance Count Verification

• Shift-to-shift count records reviewed
  Verify count sheets, shift handoff counts, and perpetual inventory records for the affected medication(s).
• Witnessed counts match documented inventory
  Confirm that two-person counts or witness signatures align with the actual on-hand quantity and documented transactions.
• Variance amount documented
  Record the quantity variance identified during count reconciliation.
• Count reconciliation method documented
  Describe how the count was reconciled, including timestamps, locations, and staff involved.

Witness Verification and Chain of Custody

• Witness signatures verified for all required count events
  Confirm required witness signatures or initials are present for counts, wastes, returns, and discrepancies.
• Witnesses independently confirmed the count or waste
  Interview witnesses to confirm they observed the count, waste, or transaction in real time rather than signing retrospectively.
• Chain-of-custody gaps identified
  Determine whether any medication transfer, storage, access, or disposal step lacked traceable documentation.

Staff Interviews and Access Review

• Primary staff member interviewed
  Document whether the staff member assigned to the affected medication, shift, or cart was interviewed.
• Additional staff or witnesses interviewed
  Confirm interviews were completed with charge nurse, supervisor, witnesses, or other staff with relevant access or observations.
• Access patterns reviewed for the affected medication storage area
  Review badge access, key control, cart access, or cabinet access logs where available.
• Interview summary and key statements documented
  Summarize relevant statements, inconsistencies, explanations, and any admissions or denials.

Pharmacy Follow-Up, Reporting, and Corrective Action

• Pharmacy notified of discrepancy
  Confirm the dispensing pharmacy or consultant pharmacist was notified of the suspected diversion or count discrepancy.
• Pharmacy response and recommendations documented
  Record any pharmacy guidance regarding replacement supply, inventory review, reporting, or medication security controls.
• Corrective actions assigned with owner and due date
  Document corrective actions such as retraining, access restriction, enhanced counts, policy review, or escalation to compliance/risk management.
• Regulatory or internal reporting completed as required
  Verify reporting obligations were evaluated and completed according to facility policy, state law, and applicable controlled substance requirements.