Misappropriation of Controlled Medications by ADON
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of their controlled medications, specifically Norco (hydrocodone/acetaminophen) and morphine. The Assistant Director of Nursing (ADON) removed over 150 tablets of Norco and a bottle of morphine from the medication cart without proper authorization or following established procedures. The ADON claimed to be conducting a narcotics audit and told staff that medications not used for 90 days or discontinued would be removed, but there was no evidence that these medications were discontinued or that the resident was not returning. The medications were never recovered. The resident affected had a history of dementia, diabetes, end-stage renal disease, chronic pain due to neuropathy from a below-knee amputation, and had recently undergone a toe amputation. Upon returning from the hospital, the resident was unable to receive his prescribed Norco for pain management because the medication had been removed from the cart. Instead, he was given Tylenol with codeine, which he reported did not adequately relieve his pain. Documentation showed that the resident experienced pain levels of 7-8 for two to three days following his return, which would have been managed with the missing Norco. Multiple staff interviews confirmed that the ADON removed the narcotic medication cards from the cart, citing incorrect facility policy and without proper verification or discontinuation orders. Staff did not initially question the ADON's actions due to her management position. The facility's prior policy allowed nurses to discard empty narcotic cards themselves, but the removal of full cards with active orders was not permitted. The incident was discovered when staff noticed the missing medication and reported it to the Director of Nursing, who confirmed that the medications had not been discontinued or destroyed according to protocol.