Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
A medication card containing 43 tablets of a compound narcotic pain medication prescribed to a resident with severe cognitive impairment and multiple medical conditions was taken from a medication cart. The incident occurred after an LPN left the medication cart unlocked while attending to an emergency on a secure unit. Upon returning, the LPN found the cart and the narcotic box unlocked but did not immediately check for missing items. The missing medication was later discovered during a shift change narcotic count between the outgoing LPN and incoming RN, revealing a discrepancy between the narcotic book count and the actual number of pills present. The investigation found that the narcotic box lock on the medication cart was not functioning properly, requiring either a key or forceful closure to secure it. Staff reported that this issue with the lock had been ongoing, but there was no clear documentation of when it was first noticed. The medication card, still bearing the resident's identifying information, was eventually found empty in a dumpster behind the facility after a search by the DON, ADON, and Administrator. The resident involved had diagnoses including osteoporosis, dementia, and cervicalgia, and was dependent on staff for most activities of daily living. The resident was receiving scheduled and as-needed opioid pain medication, with care plans in place to monitor for side effects and signs of overdose. Facility policy required protection of residents from misappropriation of property, but the failure to secure the medication cart and narcotic box led to the wrongful use of the resident's medication.