Misappropriation of Resident Medications by LVN
Penalty
Summary
A licensed vocational nurse (LVN) was found to have taken controlled substances, including pain medications and a syringe of an unknown substance, belonging to two residents at the end of his shift. The incident was observed by a registered nurse (RN), who noticed the LVN behaving erratically and discovered the medications in his possession as he was leaving the facility. The LVN admitted to taking the narcotics and other pills from the medication cart. Subsequent checks revealed that the controlled substance counts were not correct at the end of the shift, and specific doses of pain medication had not been administered to the affected residents. The two residents involved had significant medical histories, including chronic pain, dementia, and other comorbidities. One resident was found to have missed her morning dose of Lorazepam and reported a pain level of 9 out of 10, while the other missed her dose of Tramadol and reported a pain level of 6 out of 10. Medication administration records confirmed that the medications were not given as ordered, and pain assessment rounds corroborated the residents' reports of unrelieved pain. The facility's medication count records and interviews with staff further confirmed the discrepancies and the failure to administer the prescribed medications. The LVN had a documented history of disciplinary issues related to medication administration and charting, including previous write-ups for leaving the medication cart unlocked, medication errors, and incomplete charting. Despite these issues, the LVN continued to work in the facility due to a progressive discipline policy. The facility's policy required secure storage and reconciliation of controlled substances, but the procedures were not effectively followed, resulting in the misappropriation of resident medications and failure to protect residents from exploitation.