Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A facility failed to protect a resident's right to be free from misappropriation of property, specifically controlled medication. A resident with severe cognitive impairment and diagnoses including depression, anxiety disorder, and dementia had a physician's order for lorazepam to be administered as needed. Two lorazepam pills, which were prescribed for this resident, were discovered in another resident's room by the Administrator in Training (AIT). The AIT reported the finding to a nurse, who took possession of the pills and stated she would waste them after her medication pass. Subsequent review of the controlled medication count sheet revealed that the nurse had signed out two lorazepam tablets for the resident and documented them as wasted, with another nurse signing as a witness. However, interviews revealed that the witnessing nurse had not actually observed the wasting of the medication and acknowledged she should not have signed the sheet. The medication administration record showed that the lorazepam had not been administered to the resident as ordered, and documentation was incomplete regarding the handling and disposal of the controlled medication. The investigation substantiated that the nurse had diverted the resident's medication, as the pills were found in another resident's room and the required documentation and witnessing of medication waste were not properly completed. The involved staff members were no longer employed at the facility at the time of follow-up interviews, and the incident was reported to the appropriate regulatory board.