Misappropriation of Resident Medications by Nursing Staff
Penalty
Summary
Multiple nursing staff at the facility engaged in the practice of taking medications prescribed for one resident and administering them to other residents when their own medication supply ran out. This was observed across several residents, with medication cards showing doses removed and annotated for use by other residents, often without proper documentation or consent. The medications involved included levothyroxine, potassium chloride, glipizide, clozapine, oxycodone, and pregabalin. In several cases, there was no indication or explanation for the removal of doses, and the medication cards were marked with initials or notes referencing other residents. Interviews with nursing staff revealed that this practice was directed by the Director of Nursing (DON) and other supervisory nurses, who instructed staff to borrow medications from one resident to give to another. Staff reported that this was a common occurrence, sometimes happening every other day, and that they had received education from the DON on how to borrow medications, though the date of this education was unclear. Staff described a process of contacting the DON or other RNs for direction when a resident's medication was unavailable, and being told to use another resident's supply. Residents and family members interviewed were not aware that medications had been borrowed from them or their family members, and had not been asked for consent. The facility's policy on abuse, neglect, and exploitation defines misappropriation of resident property as the wrongful use of a resident's belongings without consent. The actions observed and described in interviews constitute misappropriation of property, as medications were taken from residents without their knowledge or permission and used for other residents.