Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of property, specifically narcotic medications, for five residents. Clinical record reviews revealed that residents with various diagnoses, including chronic kidney disease, osteomyelitis, pneumonia, cerebral palsy, and diabetes, had physician orders for narcotic pain medications such as hydrocodone-acetaminophen, oxycodone-acetaminophen, and tramadol. These medications were found to be missing during routine checks and investigations. Interviews with the Director of Nursing (DON), Administrator, and nursing staff indicated discrepancies in the narcotic count, with specific instances where an LPN took possession of controlled substances for destruction but failed to account for their whereabouts. In one case, an LPN removed 30 tablets of hydrocodone-acetaminophen for destruction but could not explain their disappearance. Additional missing medications included oxycodone-acetaminophen, tramadol, and significant quantities of hydrocodone-acetaminophen from the narcotic lock box for multiple residents. The facility's investigation confirmed these losses, and the LPN involved was placed on leave and subsequently terminated. Facility policies required that discontinued controlled drugs be destroyed in the presence of the DON or a registered nurse, and that all scheduled drugs be counted at the beginning and end of each shift. However, the investigation and interviews revealed that these procedures were not consistently followed, leading to the unaccounted loss of narcotic medications prescribed to residents. The failure to adhere to established protocols resulted in the misappropriation of residents' property.