Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of their narcotic pain medication. The resident, who had diagnoses including rheumatoid arthritis, chronic pain syndrome, peripheral vascular disease, and gout, was cognitively intact and generally independent in activities of daily living. The resident was prescribed Oxycodone for severe pain, along with other pain medications, and was to receive these medications as needed according to physician orders. On specific dates, the resident reported not receiving their prescribed Oxycodone as requested, instead being given Tylenol and Baclofen by an LPN. The resident was aware of the appearance and effects of their medications and stated that the pain relief expected from Oxycodone was not achieved. Documentation on the Medication Administration Record indicated that Oxycodone was signed out as administered three times by the LPN, but the resident and a guest both stated that these doses were not actually given. Additionally, the narcotic count sheet and the empty medication card could not be located, and the pharmacy confirmed that the resident should have had enough medication remaining. Interviews with staff and review of witness statements revealed inconsistencies in the LPN's account of medication administration and the handling of the narcotic count sheet. The LPN reported the medication as depleted and removed the count sheet and card, which were subsequently missing. The facility's investigation, after initial mismanagement, determined that three tablets of Oxycodone were unaccounted for and had been misappropriated by the LPN, constituting a failure to protect the resident's property as required by facility policy.