Failure to Prevent Drug Diversion of Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when approximately 1 mL of the resident's liquid morphine sulfate, a controlled medication, was found missing during a narcotic count audit. The incident was discovered during a shift change, and the discrepancy was noted by two LVNs who reported the missing medication to the DON and Administrator. Multiple staff members who had access to the medication cart were interviewed and required to provide statements and drug screens. Several nurses either refused the drug screen or could not be located for testing, and one nurse suspected of diversion left the facility and did not return for testing. The resident involved was an elderly male with Alzheimer's disease, prostate cancer, and a history of fractures, who was receiving hospice care and scheduled as well as PRN pain medications, including liquid morphine sulfate. The resident had severe cognitive impairment and was unable to advocate for himself. Documentation showed that the resident received morphine as ordered, and there were no reports of pain exacerbation or adverse effects during the period in question. The medication administration records and witness statements from staff were reviewed, and no other discrepancies were found in the narcotic counts for this or other residents. Staff interviews revealed that some nurses had observed suspicious behavior from the nurse suspected of diversion, including sleeping on the job and slurred speech, and that management was aware of these behaviors prior to the incident. The facility's investigation included reviewing medication administration records, interviewing staff, and conducting drug screens. The incident was reported to the appropriate authorities, and the facility followed its drug diversion protocol as outlined in its policies.