Failure to Prevent Misappropriation of Resident's Controlled Substances
Penalty
Summary
A deficiency occurred when a resident's controlled substances, specifically Oxycodone and Diazepam, were misappropriated and became unavailable for administration. The resident, who had diagnoses including malignant neoplasm of the anus, depression, neoplasm-related pain, insomnia, and osteoarthritis, was cognitively intact at the time. The medications were delivered to the facility and signed for by an agency nurse, but when the night nurse attempted to dispense them, the narcotics were missing. Multiple staff members, including the agency nurse and other nurses on the unit, were interviewed and drug tested, all with negative results. The investigation into the missing medications was inconclusive, as the controlled substances and their accompanying paperwork were not found, and staff who received other medications from the delivery did not receive the narcotics. The facility's review of records, witness statements, and proof of delivery confirmed that the agency nurse signed for the medications, but only non-controlled prescriptions were handed off to other staff. The missing medications were not located in the medication carts or medication room, and no missed doses were noted in the Medication Administration Records for residents on the unit. The facility's policy prohibits misappropriation of resident property, including medications, but the controlled substances for this resident were not protected from wrongful use or loss.