Failure to Protect Residents from Misappropriation of Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of their medications when gabapentin prescribed to three residents went missing and was unaccounted for while in the facility’s possession. The missing medications were discovered after a nurse reported suspicious behavior by a certified medication technician (CMT), who was observed popping pills out of medication cards, tearing off the tops, and placing the pills in a personal backpack. Labels from the medication cards for three residents were later found in the shred bin, and audits revealed significant discrepancies in the number of gabapentin pills that should have been available for each resident compared to what was actually present. The residents affected had documented needs for pain management, with physician orders and care plans specifying regular administration of gabapentin for conditions such as neuralgia, neuritis, generalized muscle weakness, and chronic pain syndrome. Medication administration records and pharmacy delivery slips confirmed that the medications had been delivered and should have been available, but audits showed that large quantities were missing. For example, one resident was in the hospital at the time the medication went missing, yet their supply of gabapentin could not be located, while two other residents had far fewer pills available than expected based on recent pharmacy deliveries and administration records. Interviews with staff confirmed that only nurses and CMTs had access to resident medications, which were kept locked in medication carts or rooms. Staff described the process for disposing of medication labels and the protocol for reporting suspected misappropriation. The incident was reported to the Director of Nursing (DON) and the Administrator, and the Department of Health and Senior Services (DHSS) was notified. The deficiency centers on the facility’s failure to ensure the security and proper accounting of resident medications, resulting in the wrongful use or misappropriation of residents’ property.