Failure to Prevent Theft of Controlled Medications
Penalty
Summary
The facility failed to prevent the theft of controlled medications belonging to one resident. According to the report, a registered nurse (RN) requested an LPN to provide excess medications from the narcotic box, specifically naming the medications she wanted, including Hydrocodone prescribed to the resident. The LPN, being new and unfamiliar with procedures, handed over the medication cards to the RN, who then proceeded toward the Director of Nursing's (DON) office. Video footage later confirmed the RN entered the DON's office with several medication bottles and pill cards but left still carrying the pill cards. The DON only received two bottles of liquid medication, not the Hydrocodone cards. The RN was unable to account for the missing medications when questioned and was the last person seen with them. The investigation substantiated the allegation of missing narcotics, with a total of 64 Hydrocodone tablets unaccounted for. The incident was reported to local police, and a thorough search of medication carts did not recover the missing narcotics. The resident had an as-needed order for Hydrocodone and did not go without medication, as they had not requested it during the period in question. The facility's policies required safeguards to prevent misappropriation of resident property and controlled substances, but these were not effectively implemented in this instance, resulting in the misappropriation of the resident's medication.