Failure to Prevent and Report Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to implement effective processes to prevent the misappropriation of residents' controlled medications for four residents. According to facility policy, nursing staff are required to count controlled medications at the end of each shift, with both the oncoming and outgoing nurses present, and to document and report any discrepancies to the Director of Nursing Services. However, review of medication logs and pharmacy packages revealed that multiple tablets of controlled substances, including Hydrocodone/Acetaminophen, Oxycodone/Acetaminophen, Oxycodone, and Chlordiazepoxide, were unaccounted for across four residents. Photographic evidence was obtained to document the discrepancies between the inventory logs and the actual medication counts. Interviews with the DON and Administrator revealed that the missing medications were discovered after a nurse, who was assigned to the medication cart, left the facility several times during her shift with the medication cart keys and did not follow proper sign-out procedures. The nurse also refused to count the controlled medications with the oncoming nurse and left the facility abruptly, after which the discrepancies were discovered. The DON reported the incident to the local police and the Board of Nursing but did not conduct an internal investigation or report the misappropriation to the State Agency, based on advice from the Regional Nurse Consultant, who believed that replacing the medications for the residents was sufficient. Residents affected by the missing medications were informed by the facility that some of their medications had been taken, which caused distress and concern for their safety. One resident reported feeling unsafe and not receiving follow-up information about the outcome of the incident. The facility's failure to follow its own policies and regulatory requirements resulted in the misappropriation of resident property and a lack of appropriate reporting and investigation.