Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
A facility failed to prevent the misappropriation of a resident's controlled medications, specifically hydrocodone/acetaminophen and oxycodone, which were prescribed for pain management. The resident involved had dementia, a history of falls, atrial fibrillation, and was receiving hospice care at the time of the incident. Pharmacy records showed multiple deliveries of controlled substances, and medication administration records indicated that doses were given as ordered. However, discrepancies were found between the number of doses administered and the available count sheets, with missing declining count sheets and unaccounted-for medication blister packs. The investigation revealed that early refill requests were made for the resident's medications, and the pharmacy notified the facility that it was too soon to dispense additional medication. Despite this, the facility reordered the medication at its own expense to ensure the resident did not miss any doses. During the review, it was discovered that there were missing count sheets for both hydrocodone/acetaminophen and oxycodone, and at least 30 pills of each medication were unaccounted for. Staff interviews and record reviews indicated that two nurses were last in possession of the medications, but one nurse could not be reached for follow-up, and the other denied involvement. There was no evidence that the missing medications were returned to the pharmacy or that the required documentation was completed. The facility's internal investigation included audits of controlled substance count sheets, packing slips, and return forms, as well as interviews with staff. The Director of Nursing confirmed that the root cause of the missing medications could not be determined, but drug diversion was substantiated for the resident's narcotic medications. The resident did not miss any scheduled doses, and pain assessments were conducted to ensure effective pain management. The incident was reported to regulatory agencies, but the facility was unable to identify the individual responsible for the misappropriation.