Failure to Protect Resident from Misappropriation and Exploitation by Staff
Penalty
Summary
A resident with multiple sclerosis, neurogenic bladder, anxiety, and depression, and who was cognitively intact, was not protected from misappropriation of property and exploitation. The resident had a prescription for Sildenafil Citrate, with multiple shipments documented from the pharmacy. Medication Administration Records (MAR) and progress notes failed to account for a significant number of tablets from several medication cards, with between 21 and 33 tablets unaccounted for over several months. The facility could not provide documentation regarding the disposition of these missing medications, and the medication cards were not found in the medication cart, storage room, or pharmacy bin. The resident reported a close relationship with a registered nurse, to whom he gave money as a tip for her birthday. He also indicated that this nurse was the only person who administered his Sildenafil Citrate. Staff interviews revealed observations of an unprofessional relationship between the nurse and the resident, including reports of inappropriate physical contact and private time together. Other staff reported hearing that the nurse took medications belonging to residents, including the resident's Sildenafil Citrate, and that the resident gave the nurse money for personal reasons. A police investigation found a prescription label for the resident's Sildenafil Citrate in the nurse's personal belongings. The facility's administrator confirmed that the nurse was the only staff member who administered the medication and that the missing medication was not returned to the pharmacy. The facility's policies required immediate investigation and thorough documentation of abuse, neglect, exploitation, and misappropriation, but the documentation and oversight were insufficient to prevent or account for the misappropriation of the resident's medication and money.