Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
A deficiency occurred when the facility failed to prevent the misappropriation of a resident's controlled medication. A cognitively intact resident with multiple diagnoses, including congestive heart failure, schizoaffective disorder, generalized anxiety disorder, and chronic pain syndrome, had been dispensed hydrocodone-acetaminophen tablets. The controlled substance administration record indicated a discrepancy in the number of tablets remaining, and a subsequent review revealed that a blister pack containing the medication, which was scheduled for destruction, had gone missing. An investigation found that the Housekeeping Supervisor removed the blister pack from a plastic bag in the conference room, took several pills, and then discarded the remaining blister pack in another resident's room. The Housekeeping Supervisor later admitted to taking the medication and attempting to conceal the act by pretending to have found the blister pack. The incident was confirmed through staff interviews and review of facility records.