Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled medications for nine residents, as evidenced by discrepancies between the controlled substance dispense logs and the medication administration records (MARs). The facility's policy strictly prohibits the misappropriation of resident property, including medications, but an audit revealed that an LPN signed out doses of Norco and Oxycodone for multiple residents without documentation that the medications were administered. In several cases, the residents' MARs and clinical records contained no evidence that the signed-out doses were given, and interviews with alert residents confirmed they did not receive the medications at the documented times. The residents affected included both cognitively impaired and cognitively intact individuals, many of whom had orders for as-needed or routine opioid pain medications due to frequent or constant pain. The controlled drug records showed that doses were removed from the blister cards and signed out for administration, but there was no corresponding documentation in the MARs or clinical records to indicate that the medications were actually provided to the residents. For residents who were not alert and oriented, records indicated they did not routinely request as-needed pain medications, further supporting the finding that the medications were not administered as documented. The facility's investigation identified a pattern of misappropriation by the LPN, who removed and signed out narcotics for the affected residents without administering them. This was confirmed through record reviews, resident interviews, and the facility's own investigation, which concluded that the LPN had diverted the medications for personal use or other unauthorized purposes. The deficiency was cited under state regulations related to the responsibility of license, management, and nursing services.