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F0602
D

Misappropriation of Resident Medication by LVN

Marshall, Texas Survey Completed on 04-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse (LVN) was found in possession of a resident's prescribed medication, Promethazine-Dextromethorphan, outside of the facility. The medication, which was ordered to be administered via gastrostomy as needed for nausea, was discovered during a traffic stop by local law enforcement. The bottle was labeled with the resident's name and was found in the LVN's personal bag. The LVN was unable to provide a satisfactory explanation for how the medication ended up in her possession. The resident involved was a male with significant medical conditions, including cerebral infarction, hemiplegia, hemiparesis, type 2 diabetes, epilepsy, and a gastrostomy. He had severely impaired cognition, as indicated by a BIMS score of 00, and his care plan included interventions for impaired cognitive function and medication administration as ordered. However, the care plan did not specifically address the use of Promethazine-Dextromethorphan Syrup. Prior to the incident, the facility did not have clear documentation of where the resident's medication was stored, with reports indicating it could have been kept in either the medication cart or the resident's room. The incident was reported to the facility by the county sheriff's office, and subsequent interviews with facility leadership confirmed that the LVN had no prior disciplinary issues or suspicious behavior reported. The facility was unaware of the medication's whereabouts prior to the incident and had to reorder the missing medication. The LVN was terminated for failing to adhere to the corporate code of conduct after being found with the resident's medication outside the facility.

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