Failure to Protect Resident's Controlled Medication from Misappropriation
Penalty
Summary
A deficiency occurred when a resident's controlled pain medication, Oxycodone-acetaminophen 7.5-325 mg, went missing from the medication cart. The resident, who was cognitively intact and had diagnoses including diabetes mellitus, right tibia fracture, cellulitis, and right leg pain, was prescribed this medication both on a scheduled and as-needed basis. On the morning in question, an LPN administered a dose to the resident and confirmed that four tablets remained. During the shift, the LPN gave the medication cart keys to the Unit Manager, who, along with another LPN, placed additional medication cards in the lock box but did not perform a count of the controlled substances afterward. At the end of the day shift, during the routine medication count, it was discovered that the resident's Oxycodone-acetaminophen medication card was missing. The evening shift RN and the LPN confirmed the absence of the medication card during their count, and the incident was reported to the Director of Nursing. Facility policy required all Class II drugs to be stored under double lock at all times and for the environment to be free from misappropriation of resident property. The failure to properly secure and account for the controlled medication led to the misappropriation of the resident's property.