Failure to Prevent Diversion of Controlled Medications by Nursing Staff
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically the diversion of controlled medications by a registered nurse (RN). Facility policy required strict compliance with laws and regulations regarding the handling, storage, and documentation of controlled substances, including shift-to-shift narcotic counts and immediate reporting and investigation of discrepancies. Despite these policies, a review of controlled drug administration records revealed that the RN signed out and documented the administration of opioid medications to three residents on days when the RN was not scheduled to work. In several instances, the RN signed out extra doses, documented medication wastage with unverified witnesses, and duplicated entries for the same medication, indicating unauthorized removal of controlled substances. The three residents affected had significant medical histories, including chronic pain, orthopedic aftercare, diabetes, dementia, heart failure, and hypertension. Their medical records showed regular physician orders for opioid pain medications, and medication administration records indicated that pain levels were assessed every shift. However, discrepancies in the controlled drug records showed that the RN diverted medications intended for these residents, sometimes signing out doses that were not administered or were not witnessed by appropriate staff. In one case, the RN admitted to taking a total of 11 tablets from three different residents for personal use. The facility's investigation included audits of narcotic records, resident assessments to ensure pain control, and interviews with involved staff. The RN, who was known to be participating in a professional assistance program for substance use, admitted to the diversion of medications. The facility notified law enforcement and the provider pharmacy regarding the missing medications. Despite the diversion, documentation indicated that residents did not report issues with pain management or distress during the period in question.