Misappropriation of Controlled Pain Medication by LPN
Penalty
Summary
The facility failed to protect a resident from the misappropriation of a controlled pain medication. According to the investigation, an LPN removed three tablets of Oxycodone 5 mg from the resident's supply and replaced them with unidentified tablets in a medication cup. The LPN then asked another LPN, who was coming on shift, to administer the medication to the resident upon their return to the facility. When the second LPN prepared to administer the medication, she noticed the tablets did not match the description of the prescribed opioid in the pharmaceutical packaging. She sought a second opinion from another licensed nurse, who confirmed the discrepancy, and then notified the supervisor. Further review of the narcotic log and the Medication Administration Record (MAR) revealed no discrepancies, but an inventory of the medication carts confirmed that one resident was missing three tablets of Oxycodone 5 mg. Staff interviews corroborated that the medication left in the cup did not match the resident's prescribed medication. The incident was reported and investigated, confirming the misappropriation of the resident's controlled pain medication.