Narcotic Diversion and Misappropriation of Resident Medication
Penalty
Summary
A deficiency occurred when a resident's controlled medication, specifically oxycodone, was found to be missing from the facility's narcotic storage. The facility's policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings without consent. In this case, 120 oxycodone pills were delivered for a resident, but only 24 pills were documented as administered according to the Medication Administration Record. Upon investigation, it was discovered that 36 pills were unaccounted for, and the medication card was missing from the designated shred box, despite staff statements that it had been properly disposed of. The Controlled Drug Record and pharmacy receipts confirmed the delivery and subsequent removal of the medication card, but the required documentation and physical evidence of the card's destruction were absent. Interviews with the DON and LPNs involved revealed inconsistencies in the handling and documentation of the resident's narcotic medication. The DON confirmed that she was unable to locate the medication card or the corresponding narcotic sheet in the appropriate storage locations. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had an active order for oxycodone 10 mg every six hours as needed for pain. The failure to account for all administered and remaining pills, as well as the lack of proper documentation and secure handling of the medication card, led to the determination of narcotic diversion and misappropriation of resident property.