Misappropriation of Narcotic Medication in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of resident property, specifically involving the diversion of narcotic medication for two residents. Resident R69, who was admitted with diagnoses including dementia, chronic pain, and arthritis, was receiving hospice care and had a physician order for morphine sulfate to manage pain. Similarly, Resident R262, also with dementia and chronic pain, was on hospice care and had a physician order for morphine sulfate for pain and shortness of breath. An incident was reported when a nurse noticed that the morphine for Resident R262 appeared altered, with a paler color and a mint-like smell, which was consistent with mouthwash. Further investigation revealed that the morphine for Resident R69 was also tampered with, and laboratory testing confirmed that the morphine concentration for Resident R262 was diluted. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the misappropriation of morphine for both residents. Despite the tampering, Resident R69 reported adequate pain management and did not experience increased pain. The facility conducted drug tests on all nurses with access to the medication, which returned negative results for opiates. The local police department was contacted but declined to investigate the matter further.
Plan Of Correction
A - Resident R262 expired and cannot be corrected. Resident R69 had a replacement bottle of morphine ordered and charged to the facility. B - Audit of all incidents of misappropriation of narcotics in last 30 days to ensure facility replaced medication at facility's cost. C - Previous DON and NHA educated on process of replacing any misappropriated narcotic medications at the cost of the facility. Current DON and NHA are aware of this process. D - Weekly x 4 then monthly x 2 audits by DON or designee of misappropriated narcotic medications to ensure replacement at the cost of the facility. Results discussed during QAPI meetings.