Misappropriation and Falsification of Controlled Medication Records
Penalty
Summary
The facility failed to protect two residents from misappropriation of their controlled medications. During a random controlled substance audit, discrepancies were found in the documentation of medication administration for two residents. Specifically, several entries for controlled medications were signed out on the count sheet by a licensed nurse but were not documented on the Electronic Medication Administration Record (EMAR). Further review revealed that medications were signed out as being destroyed using another nurse's initials, as well as initials that did not belong to any licensed staff at the facility. The investigation found that on multiple occasions, controlled medications such as hydrocodone-acetaminophen, tramadol, and oxycodone were signed out and either not documented as administered or were documented as destroyed with falsified witness signatures. In one instance, a medication was signed out for a resident who was not present in the facility, having been admitted to the hospital at the time. Interviews with the nurse whose initials were used as a witness confirmed that she did not participate in the destruction of the medications and had not given permission for her initials to be used. Other licensed staff also denied witnessing or participating in the destruction of these medications. The nurse responsible for the discrepancies was unable to provide a consistent explanation for the documentation issues and admitted to signing another nurse's initials, claiming permission had been given, which was denied by the other nurse. The facility's policies required two licensed nurses to be present for the destruction of controlled substances and for accurate documentation of medication administration, which was not followed in these instances. The events led to the identification of missing medications and falsified records, placing the residents at risk for missed medications and further misappropriation.