Failure to Protect Resident from Misappropriation of Controlled Substance
Penalty
Summary
A deficiency occurred when a resident with a history of multiple fractures and chronic pain, who was prescribed Methadone for pain management, did not receive a scheduled morning dose of Methadone. The medication was documented as not available, despite a pharmacy delivery of Methadone tablets to the facility that afternoon. The resident's medication administration record and declining inventory sheet showed discrepancies in the documentation of Methadone administration, including missing times and doses signed out at times when the assigned nurse was not on duty. Nurse assignment records indicated that the nurse responsible for administering the Methadone was present during the relevant shifts, but failed to document the administration times accurately. The nurse admitted to administering the medication at times not consistent with the physician's order and did not contact the physician for guidance regarding the missed dose. The resident reported only receiving one dose of Methadone that day and experienced discomfort, though it was unclear if this was directly related to the missed medication. The facility's investigation revealed that the nurse signed out two doses of Methadone on the inventory sheet, with one dose recorded at a time when the nurse was not present in the facility. The physician was not informed of the missed dose, and the resident's account was later credited for the missing medication. The incident was identified through a medication count discrepancy and reported by another nurse to the Director of Nursing, prompting an internal investigation.