Failure to Secure Controlled Substances Resulting in Misappropriation
Penalty
Summary
A deficiency occurred when a resident's controlled medication, specifically a card of oxycodone HCL 5 mg tablets, went missing from a medication cart. The medication was prescribed for the resident to be taken as needed, and the prescription was filled with 18 tablets, with one tablet administered and 17 remaining. During a routine narcotic count at shift change, it was discovered that the entire card of 17 tablets was missing. The incident was reported, and an investigation was initiated. The investigation revealed that during the night shift, two nurses shared a medication cart and only had one set of keys. One of the nurses admitted to leaving the narcotic keys on top of the medication cart during her breaks, rather than keeping them on her person or handing them to another nurse, as required by facility policy. This practice was contrary to the facility's expectations and created an opportunity for the medication to be taken without authorization. Interviews with staff confirmed that the keys should always be kept with a nurse and never left unattended on the cart. Attempts to interview all staff involved were not fully successful, but available witness statements and interviews confirmed the improper handling of narcotic keys. The missing medication was not recovered, and the incident was reported to the appropriate authorities, including the local police and the DEA. The nurse involved was later charged with felony larceny by an employee. The facility failed to protect the resident's property by not ensuring proper security of controlled substances.