Failure to Secure and Account for Controlled Substance Resulting in Misappropriation
Penalty
Summary
The facility failed to protect a resident's property by not ensuring the proper storage and accounting of a controlled substance, Lorazepam Oral Concentrate, prescribed as needed for anxiety. The medication was delivered and signed for by an LVN, but was placed in a refrigerator in the medication room instead of the required double-locked storage, as the lock box was reportedly broken and could not be opened. The medication was subsequently unaccounted for and its whereabouts remain unknown. Multiple staff members, including nurses and medication aides, had access to the medication room and refrigerator, and there was only one key to the lock box, which was not used. The medication was not administered to the resident during the period in question, as there was no documented need for it. The resident involved was an elderly female with severe cognitive impairment, a history of sacral fracture, pressure ulcer, dementia, and anxiety disorder. The facility's investigation confirmed the misappropriation of the controlled substance and identified failures in following policy for narcotic counts and secure storage. The incident was not detected until several days after the medication was delivered, and the required narcotic counts were not performed correctly, allowing the misappropriation to go unnoticed.