Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a significant quantity of the resident's prescribed narcotic medication, Oxycodone 5mg tablets, was found missing. The resident, who had diagnoses including depression, dementia, heart disease, and low back pain, was prescribed Oxycodone to be taken every eight hours. The missing medication was discovered after it had been received and verified by staff, but the loss was not identified until the middle of a shift rather than at shift change, as required by policy. The facility's investigation did not clearly state the reason for initiation, did not identify an alleged perpetrator, and failed to address inventory procedures or pinpoint when the medication went missing. Interviews with staff and review of facility policies revealed that, at the time of the incident, the process for counting controlled substances was inadequate. Staff only counted in-use sheets of narcotics and did not include full, unopened sheets in their shift-end counts, making it impossible to determine when the medication was taken or who was responsible. The count sheets and medications were accessible to all staff with access to controlled drugs, and the lack of comprehensive inventory controls prevented the facility from identifying the responsible party or the exact timing of the loss. The police investigation also noted the absence of proper inventory controls over the controlled medication.