Failure to Prevent Misappropriation of Resident's Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her prescribed oxycodone HCl Oral Tablet 5 MG, which was received through hospice care. The resident, an elderly female with chronic pain, chronic kidney disease stage 5, and a pathological femur fracture, was on a scheduled pain medication regimen and required maximal assistance with hygiene and bathing. Her cognitive status was moderately impaired, as indicated by a BIMS score of 08. The resident had both routine and PRN orders for oxycodone, but no PRN doses were administered during the month in question. On April 10, a hospice nurse counted the resident's medications and confirmed the presence of 16 PRN oxycodone tablets. By April 18, the same nurse discovered that the PRN oxycodone blister pack and the corresponding narcotic count sheet were missing from the narcotic box and book. Nursing management was unable to locate the missing medication or documentation. A review of the narcotics count sheet revealed a mathematical error in the count on April 11, which may have contributed to the loss going undetected. The resident reported always receiving her pain medication when needed and had no concerns regarding her pain management. Interviews with staff confirmed awareness of the drug diversion incident and knowledge of the procedures for narcotic counts and medication cart key transfers. The facility's investigation included interviews and drug testing of all staff with access to the medication cart during the relevant period, but no perpetrator was identified. The facility's policies prohibit misappropriation of resident property, including drug diversion, and require accurate recording and reconciliation of controlled substances. The incident was reported to the police, and the resident's family and medical director were notified.