Misappropriation of Resident Medication by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her medication. The incident involved a resident who was admitted with multiple diagnoses, including a right femur fracture, and had an order for Tramadol 50 mg every six hours as needed for pain. The resident was cognitively intact and required varying levels of assistance with daily activities. On the evening of the incident, a discrepancy was noted in the narcotic count for the resident's Tramadol, with one pill unaccounted for. A nurse finishing her shift admitted to removing the medication from the cart but stated it was too early to administer, so she placed it in her pocket. When it was time to give the medication, she could not locate it. After assisting another staff member, she claimed to have found the missing pill and disposed of it, but no evidence of the discarded medication was found during a subsequent search. The nurse left the facility before she could be questioned further and refused to return or cooperate with the investigation, ultimately terminating her employment. The facility's investigation included reviewing medical and narcotic records, interviewing staff and the resident, and searching for the missing medication. The incident was reported to the state nursing board, and the investigation could not conclusively determine the outcome of the missing medication. The administrator confirmed that the resident's medication had been misappropriated, constituting a failure to protect the resident's property as required by facility policy.