Failure to Prevent Misappropriation of Resident Narcotics
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident with multiple complex medical conditions, including respiratory failure with hypoxia, diabetic neuropathy, dysphagia, diabetes, and chronic kidney disease. The resident had a care plan for pain management that included administration of Oxycodone 10 mg every 8 hours. According to the Medication Administration Record, the last dose of Oxycodone was administered at 2:00 P.M. on 5/14/25, and no further doses were given for the remainder of the month. During a routine narcotic audit, it was discovered that five Oxycodone tablets were missing from the resident's medication card, with the count showing 70 tablets instead of the expected 75. The missing medication was identified after a nurse noticed the narcotic cards had been repositioned and questioned the LPN who had access to the medication. The LPN did not provide an explanation and subsequently refused a drug test, left the facility abruptly, and could not be contacted afterward. Statements from staff confirmed that the narcotic count was correct prior to the LPN's shift, and the discrepancy was discovered during the LPN's shift. The incident was reported to the Director of Nursing, and the facility's policy defined such misappropriation as the wrongful use of a resident's property or medication without consent.