Failure to Prevent Misappropriation of Resident Medication Due to Inadequate Controlled Substance Inventory Procedures
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication when an LPN diverted controlled substances by falsifying the shift inventory records. The LPN initiated a new Controlled Substance Shift Inventory and recorded an incorrect number of medication blister packs, which allowed the medication to be removed without immediate detection during the shift change count with another LPN. The previous inventory sheet and pharmacy controlled substance records were missing at the time, and the discrepancy was only discovered when the oncoming nurse attempted to retrieve the medication for the resident a few hours later. The missing inventory sheet was later found in the shred box and revealed a discrepancy in the count compared to the new inventory. The DON confirmed that the oncoming nurse did not verify the new inventory against the previous one, as required by facility policy, and the oncoming LPN acknowledged not following the standard procedure for handling inventory sheets. The resident involved did not report any concerns about missing medication or pain management and was observed to be comfortable, with no overt signs of pain. Facility policies required a thorough reconciliation of controlled substances at shift change and defined misappropriation as the wrongful use of a resident's belongings or money without consent.