Failure to Account for and Safeguard Resident Medication
Penalty
Summary
The facility failed to properly identify, investigate, and prevent the misappropriation of a resident's physician-prescribed medication. A review of records showed that a resident had an active order for Fioricet, a medication for migraine headaches, with 30 capsules delivered by the pharmacy. However, only 11 capsules were documented as administered over a ten-day period, leaving 19 capsules unaccounted for. The resident reported not receiving the medication for a period of time, experiencing significant pain as a result. The facility's grievance log and investigation documentation did not accurately reflect the medication delivery and administration timeline, and the missing doses were not accounted for in the records. Further review and interviews revealed that the medication was not consistently stored in a double-locked drawer, and pharmacy audits did not include spot checks for this medication. The pharmacy consultant confirmed that Fioricet is not a controlled substance and therefore was not required to be double-locked, but acknowledged that one of its ingredients is a barbiturate. The facility's corporate DON suggested that the issue may have been due to documentation errors, as nurses failed to sign out the medication approximately 20 times. No additional packages of the medication were found, and the missing doses remained unaccounted for.