Improper Use of Staff's Personal Narcotic Medication for Resident
Penalty
Summary
A deficiency occurred when a Certified Medication Technician (CMT) brought narcotic pain medication tablets from their personal prescription into the facility and placed them into a resident's medication card. This action was taken after a discrepancy was found during the controlled medication count, where two tablets of the resident's prescribed Norco were missing. The CMT, unable to account for the missing tablets, retrieved two pills of the same medication and strength from their vehicle and taped them into the resident's medication card to correct the count. Subsequently, a staff member administered one of these non-facility-supplied pills to the resident for pain management, as documented in the medication administration record. The administration of this medication was not properly documented by the CMT on the medication administration record, and there was no entry in the resident's progress notes regarding the medication error, assessment of the resident's condition, or notification of the resident's physician following the incident. The facility's procedures for handling controlled substances and documentation were not followed, and the use of a staff member's personal medication for a resident was confirmed to be unacceptable practice by the facility's pharmacy representative. The resident involved had a history of chronic pain, low back pain, anxiety disorder, major depression, and stroke, and was cognitively intact and independent with most activities of daily living. The resident was not aware of any misappropriation of medication or property and did not report any recent increase in sedation or pain. Interviews with staff revealed confusion and lack of adherence to proper protocols regarding the administration and documentation of controlled medications, as well as delayed reporting of the incident to facility management.