Misappropriation of Controlled Medication from Resident Supplies
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed hydrocodone-acetaminophen 5-325 mg tablets. Both residents had a history of chronic pain and were admitted with pill bottles containing this controlled medication, which had been brought from home or another facility. Upon review, it was discovered that a significant number of these tablets had been replaced with extra strength Tylenol, as identified by a nurse during medication administration. The nurse used a pill identifier to confirm that the pills in the bottles were not hydrocodone-acetaminophen but Tylenol, and this was found to be the case for both residents. The facility's investigation revealed that six nurses had access to the locked medication cart from which the pills were taken. Drug testing was conducted on the nurses who had access during the relevant period, and one nurse tested positive for the medication but provided evidence of a personal prescription. However, further testing to determine if the medication in her system was within prescribed limits was inconclusive due to a lab error. The facility was unable to determine exactly when the pill swap occurred or to substantiate which staff member was responsible for the misappropriation. The police were notified, and a report was filed, but the investigation could not confirm whether the hydrocodone was present in the bottles at the time of admission. Both residents involved were assessed and reported that their pain had been well managed, with no complaints or evidence of unrelieved pain at the time of interviews and observations. The facility's policies on abuse, neglect, exploitation, and controlled substances required verification of controlled medications upon receipt, but did not specifically address the verification of medications brought in pill bottles from outside sources or the use of pharmacy blister packs for such medications. This gap in procedure contributed to the failure to prevent the misappropriation of resident property.