Failure to Prevent Diversion of Pain Medication
Penalty
Summary
The facility failed to protect the rights of two residents to be free from misappropriation of property, specifically regarding the diversion of pain medications. Both residents had orders for Norco, with one resident rarely taking the medication and the other receiving it on a scheduled basis for pain management. The medications were administered and refilled exclusively by one LVN, who was also the only person to receive the medications from the pharmacy. This allowed the LVN to divert medications when they were delivered, as she was responsible for calling in refills and receiving the deliveries without adequate oversight. The deficiency was identified after an audit revealed several cards of Norco were unaccounted for, prompting further investigation. The audit involved both the in-house and hospice pharmacies, and it was discovered that the LVN had diverted the medications upon delivery. The process in place at the time did not ensure that medications were properly secured or that there was a reliable verification system involving multiple staff members when narcotics were received from the pharmacy. Interviews with staff indicated that the standard procedure required two nurses to verify and sign for narcotics upon delivery, but this process was not consistently followed in the cases involving the two residents. The lack of adherence to established protocols for receiving and securing medications enabled the LVN to divert the narcotics without detection for an extended period.