Misappropriation of Controlled Pain Medication by Staff
Penalty
Summary
A resident with lumbar stenosis and a history of lumbar fusion was admitted with orders for Oxycodone 5mg to be administered every four hours as needed for moderate pain. The resident was cognitively intact and on a scheduled pain regimen. On one occasion, the resident reported not receiving her morning pain medication as requested, despite documentation by a nurse indicating that four doses of Oxycodone were signed out during the night shift. However, the Medication Administration Record did not show that the medication was administered to the resident on the relevant dates. An investigation revealed that the nurse responsible for the resident's care admitted to diverting two Oxycodone tablets for personal use. The nurse had signed out four doses but failed to document administration on the MAR, and the resident confirmed not receiving all prescribed doses during the shift. The incident was reported to the state and the nursing board, and the nurse was subsequently terminated. Interviews with facility staff and the resident corroborated the misappropriation of the controlled medication.