Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of medications, resulting in two residents not receiving their prescribed controlled substances as documented. An agency LPN signed out an oxycodone tablet for a resident with a femur fracture on the controlled substance log, but there was no documentation on the Medication Administration Record (MAR) that the medication was administered. Video surveillance confirmed that the LPN did not access the narcotic lock box when preparing and delivering medications to the resident’s room at the time in question. In a separate incident, another resident with a diagnosis of osteomyelitis reported not receiving his pain medication during the evening shift. The controlled substance log showed that a hydrocodone tablet was signed out and documented as administered by the same agency LPN, but video evidence revealed that the LPN did not enter the resident’s room after an early evening visit. The resident, who was cognitively intact, confirmed he did not receive his night medications, including pain medication, and that the nurse never returned after the initial visit. The Director of Nursing (DON) audited narcotic records for all residents assigned to the agency LPN and confirmed discrepancies, including medications signed out without corresponding MAR documentation and lack of observed access to the narcotic box. Staff interviews corroborated that residents reported not receiving their medications, and the DON acknowledged the risks associated with diversion of narcotics and the importance of safeguarding residents’ medications.