Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medications for four residents, as evidenced by discrepancies between medication administration records (MARs) and controlled substance logs. Multiple residents, including those with severe pain following surgery, cognitive impairments, and significant assistance needs, did not receive their prescribed narcotic medications as ordered. For example, one resident reported not receiving pain medication for an extended period, and documentation showed inconsistencies in the number of pills received versus those administered. Record reviews revealed that the number of narcotic doses documented as administered did not match the number of doses dispensed or recorded on controlled substance forms. In several cases, residents' MARs showed fewer doses given than what was documented on the controlled drug logs. Staff interviews confirmed awareness of these discrepancies, and there were concerns about drug diversion involving specific nursing staff. One nurse in particular was identified as being involved in multiple incidents where narcotic counts did not reconcile, and their behavior was described as suspicious during the investigation. The facility's policies required accurate documentation of pain medication administration and protection of residents' property, including medications. However, the observed discrepancies and staff actions indicated a failure to follow these policies, resulting in the wrongful use and potential diversion of residents' narcotic medications. The events were substantiated through interviews, record reviews, and direct observation of documentation inconsistencies.