Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications for two residents. In the first instance, a medication monitoring record for a resident with diagnoses including cerebral palsy and cervical disc disorder showed that two oxycodone 15 mg tablets were unaccounted for, with no documentation of waste, spoilage, or disposition. The discrepancy was discovered when the medication monitoring record was found in an incorrect location, and upon review, the remaining medication was missing. The resident was cognitively intact, and the medication was prescribed for pain management. In the second case, another cognitively intact resident with chronic respiratory and anxiety conditions reported that an RN had not been administering her prescribed oxycodone 15 mg, but instead was giving her an unknown white pill. Staff statements confirmed that a white pill was found taped into the resident's oxycodone packet, and that a suspicious pink liquid, purported to be destroyed oxycodone, was also observed. The resident noticed differences in her reaction to the medication and became concerned, leading to further investigation by staff. The facility's policy states that residents have the right to be free from misappropriation of property. Staff interviews and documentation revealed that the DON was made aware of both incidents but failed to report the allegations of misappropriation to the Administrator in a timely manner. The lack of proper medication reconciliation and failure to follow reporting protocols contributed to the deficiency.