Diversion of Controlled Medications by RN
Penalty
Summary
A registered nurse (RN) diverted controlled pain medications prescribed to two residents, failing to protect their belongings and medications as required. The RN, who was enrolled in a health professional assistance program, admitted to diverting oxycodone from the residents, stating that he took the PRN pain medication when the residents did not request it. The facility's medication administration records (MAR) and narcotic sign-out sheets revealed discrepancies, such as pills being signed out but not documented as administered, and vice versa. The RN was unable to specify the exact amount of medication diverted. The residents involved included one who was cognitively intact and reported no recollection of missing pain medication and felt their pain was adequately controlled, and another resident with severe cognitive impairment who also did not recall missing medication and felt their pain was managed. Review of the MARs showed that the RN documented multiple administrations of oxycodone to both residents, but further review of the narcotic sign-out sheets and MARs identified inconsistencies in documentation and pill counts. The facility's process for reviewing narcotic administration relied on matching pill counts on sign-out sheets with the documented remaining pills, without cross-referencing the MAR for actual administration. This lack of thorough review allowed the diversion to go undetected until the RN's behavior raised concerns, leading to a positive drug test and subsequent admission of diversion. The local police were notified and confirmed the RN's account matched the facility's findings.