Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their narcotic medications. Both residents had physician orders for as-needed narcotic pain medications, with pharmacy records confirming delivery and receipt of the medications by two nurses. On a subsequent date, it was discovered that each resident was missing a full card of their prescribed narcotic medication, along with the corresponding medication count sheets. The missing medications were identified during a routine medication pass, and the nurse involved noted that the residents rarely requested their as-needed pain medications, making the disappearance of an entire card suspicious. An internal investigation revealed that a nurse had documented the removal and alleged return of the medications to the pharmacy, but failed to include required information such as the residents' names and reasons for return. Further inquiry with the pharmacy confirmed that the prescription numbers provided were fictitious and that no medications had been returned. Audits of all narcotic medications and count sheets were conducted, but the missing medications and documentation were not recovered. The nurse suspected of involvement could not be reached for an interview, and the staffing agency was notified to prevent her return to the facility. Interviews with other staff members confirmed that the facility's policy required two nurses to verify and sign for narcotic deliveries, and that no discrepancies had been noted prior to the incident. The pharmacist corroborated that the pharmacy had not received any returned narcotic medications for the affected residents. The administrator and other staff confirmed the sequence of events and the steps taken to investigate the missing medications, but the narcotics and associated documentation remained unaccounted for.