Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of their controlled medications, resulting in missing narcotics for four residents. The facility's policy required that all residents be free from misappropriation of property, including medications. However, for each of the four residents reviewed, there were significant discrepancies between the number of controlled substance tablets received from the pharmacy, the number documented as administered, and the number that should have remained in the facility. In each case, the controlled substances and their declining count sheets were removed from the medication cart by the former DON, with documentation indicating the medications were to be returned to the pharmacy, but there was no record of return and the medications could not be accounted for. For one resident with anxiety and bipolar disorder, 60 tablets of clonazepam were received, but only 5 were documented as administered, leaving 55 unaccounted for after the former DON removed the medication from the cart. For three other residents with chronic pain or recent fractures, similar patterns occurred with oxycodone: the number of tablets received, administered, and remaining did not match, and significant quantities of the medication were missing after being removed from the cart by the former DON. In all cases, the declining count sheets were also missing, and there was no evidence that the medications were returned to the pharmacy as required. Interviews and documentation revealed that the process for removing and returning controlled substances was not consistently followed, particularly the requirement for two signatures when removing narcotics from the medication cart. The facility's investigation, supported by pharmacy audits and interviews with staff and law enforcement, identified a breakdown in the process that allowed the medications to go missing. Law enforcement was unable to determine the exact circumstances of the diversion due to gaps in documentation and access, but confirmed that the facility's process failures contributed to the loss of resident medications.