Failure to Prevent Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of controlled medications, specifically oxycodone, as required by its own abuse identification policy. A review of medication records showed that 60 tablets of oxycodone were delivered for a resident, but only 25 administrations were documented in the Medication Administration Record (MAR) between the delivery date and the attempted reorder. However, the declining narcotic count sheet indicated that all 60 tablets had been used, with one nurse signing off on 41 administrations, resulting in a discrepancy of 35 tablets. The issue was discovered when a nurse attempted to reorder the medication and was informed by the pharmacy that there should still be a supply remaining, prompting notification of facility leadership. Interviews with staff, pharmacy personnel, and the medical director revealed that the nurse responsible for the majority of the documented administrations could not be reached for clarification. The facility's documentation and interviews confirmed that the resident did not receive the full amount of medication as ordered, and the discrepancy was not identified until after the medication was depleted. The lack of adequate controls and monitoring allowed for the misappropriation of the resident's controlled medication, violating the resident's right to be free from wrongful use of their property.