Failure to Secure Medication Keys Led to Misappropriation of Controlled Substance
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically regarding the resident's controlled medication. Facility policy required that controlled substances be securely locked and that medication keys remain in the possession of the nurse at all times. However, an LPN left the medication keys unattended on the nurses' station desk while taking a break and later left the keys on the medication cart while a corporate nurse was checking for expired medications. These actions provided an opportunity for unauthorized access to controlled substances. The incident was discovered when the LPN attempted to retrieve a PRN pain medication for a resident and found that a card containing 30 Norco (Hydrocodone) tablets was missing. The LPN reported the missing medication to the nurse supervisor, and a search was conducted, but the medication was not located. Interviews confirmed that the LPN had been previously trained and in-serviced on the importance of keeping medication keys secured and was aware of the policy but failed to follow it on the day of the incident. The resident involved had a history of significant medical issues, including a displaced midcervical fracture of the left femur, aftercare following joint replacement surgery, and dementia, with a moderate cognitive impairment as indicated by a BIMS score of 11. The missing medication was part of the resident's prescribed pain management regimen. The facility's failure to ensure the security of controlled substances resulted in the misappropriation of the resident's medication.