Misappropriation of Controlled Substances by DON
Penalty
Summary
The facility failed to protect residents from misappropriation of their controlled medications, specifically narcotic pain medications such as morphine, oxycodone, fentanyl, hydrocodone, and tramadol. Over a period spanning from 2023 to 2025, multiple instances of missing controlled substances were identified, affecting five residents. The former Director of Nursing (DON) was found to be the only staff member with access to the office where the medications were stored, and was observed to be impaired at work, including symptoms such as vomiting, slurred speech, and unsteadiness. A urine drug screen conducted on the DON returned positive results for morphine, oxycodone, and benzodiazepines. Investigations by the facility, local police, Board of Nursing, and Board of Pharmacy revealed that the former DON had diverted controlled substances by removing discontinued, deceased, or discharged residents' medication cards from medication carts without proper documentation or destruction. The DON admitted to falsifying destruction records and self-administering the diverted medications. The facility's incident logs, police reports, and pharmacy audits documented significant discrepancies in narcotic counts, with hundreds of doses unaccounted for over the two-year period. The DON also admitted to notifying the pharmacy that medications were destroyed when they were not, and the destruction logs lacked required witness signatures. Facility policy required that controlled substances be destroyed in the presence of a Registered Nurse and another licensed professional, with proper documentation of the destruction process. However, the investigation found that these procedures were not followed, and the DON was able to divert medications without detection until the incident was discovered in February 2025. There were no prior suspicions or reports of the DON being under the influence or diverting medications before this time, and the facility had not previously identified or reported any discrepancies related to narcotics.