Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically controlled medications, for 18 of 22 residents reviewed. Facility policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. Multiple discrepancies were identified in the handling and documentation of controlled substances, including oxycodone and tramadol, for numerous residents. In one case, a cognitively intact resident with chronic kidney disease, diabetes, and post-joint surgery care needs was found to have 27 tablets of oxycodone 10 mg missing, with no accountable documentation or explanation for their destruction or loss. Statements from staff revealed confusion and lack of clarity regarding medication orders, destruction of medication cards, and missing narcotic records. Further review of medication administration records (MARs) and controlled drug logs for other residents revealed numerous instances where narcotic medications were signed out on paper controlled drug records without corresponding documentation in the MARs. These discrepancies occurred across a range of residents and medications, including oxycodone and tramadol, with missing or inconsistent documentation of administration times and dosages. In several cases, staff statements indicated that medications were destroyed or wasted without proper documentation or clear understanding of the orders, and in some instances, medication cards were found in shred boxes or were unaccounted for entirely. Interviews with facility leadership confirmed the failure to ensure residents were free from misappropriation of property, as required by state regulations. The lack of proper documentation, inconsistent narcotic counts, and inability to account for missing medications directly contributed to the deficiency. The findings were based on a comprehensive review of facility policy, clinical records, incident investigations, and staff interviews.