Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of her prescribed medication, specifically Tylenol #3 tablets. The resident, an older female with a history of malignant neoplasm of the breast, polyneuropathy, osteoarthritis, gout, and restless leg syndrome, was prescribed Tylenol #3 for pain management. Her medication administration record indicated an order for one tablet every six hours as needed for pain, with a recent fill of 30 tablets. Upon review, it was found that 10 tablets were unaccounted for, and both the narcotic count sheet and the medication blister pack/card were missing, making it impossible to verify the exact circumstances of the loss. The incident was discovered after a nurse received a call from Hospice to verify the narcotic count, which revealed a discrepancy in the number of pills remaining. The nurse confirmed that she had previously reported a count of 13 pills, but subsequent checks indicated that 10 pills were missing. The DON confirmed that, according to the medication administration record, only 20 pills had been administered, leaving 10 unaccounted for. The missing documentation and medication raised concerns about the potential diversion or misappropriation of the resident's medication. At the time of the incident, the resident reported no issues with her medications and did not appear to have missed any doses, as the facility was able to provide the necessary medication from an emergency kit until a refill was obtained. However, the lack of proper documentation and the disappearance of both the medication and the narcotic count sheet constituted a failure to ensure the resident's right to be free from misappropriation of property.