Failure to Prevent Misappropriation of Resident Medications
Penalty
Summary
The facility failed to prevent the misappropriation of residents' medications for two residents. For one resident with a history of squamous cell carcinoma and dementia, a Qualified Medication Aide (QMA) was observed by staff and on camera placing pills into a bottle and then into her pocket. Upon questioning by the Executive Director, the QMA produced a bottle containing multiple pills, including hydrocodone tablets that matched the resident's prescribed medication. Review of the controlled drug administration record showed that the resident was documented as having received hydrocodone-acetaminophen on several dates, but there was no corresponding documentation in the Electronic Medication Administration Record (EMAR) for those administrations. The Director of Nursing confirmed that the QMA was omitting documentation of the resident's PRN pain medication in the EMAR. For another resident with chronic pain and multiple comorbidities, a discrepancy was found in the controlled substance count for hydrocodone-acetaminophen. The Director of Nursing noted that one pill was missing from the controlled substance record, and although it could not be verified that the QMA had taken the narcotic, the count was incorrect. The EMAR indicated that the QMA had administered the medication to the resident, but the controlled substance log did not reflect this administration, resulting in a missing pill. The facility's policies required that all administrations of controlled substances be recorded both in the Medication Administration Record and in the controlled substance inventory at the time of administration. The abuse policy also prohibited misappropriation of resident property, including medications. In both cases, the QMA failed to follow these procedures, resulting in unaccounted-for controlled substances and lack of proper documentation.