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F0602
D

Misappropriation of Resident's Pain Medication by Nursing Staff

Orem, Utah Survey Completed on 05-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with diagnoses including cerebral infarction, respiratory failure, and chronic pain syndrome, and who was cognitively intact, reported concerns about receiving incorrect medications from a specific nurse. The resident stated that on multiple occasions, when requesting his prescribed oxycodone for pain, he was given a different colored pill, which he identified as not being his usual pain medication. The resident's daughter also witnessed the administration of a white pill instead of the expected medication and later raised the issue with facility staff. The resident experienced symptoms such as an upset stomach and noted that his pain medication supply depleted faster than expected, while his heart medication was being administered in excess, as confirmed by his physician. The facility's investigation included interviews, review of medication administration records, and examination of video footage. The footage showed the nurse in question accessing the narcotic drawer, removing medication, and placing it in her pocket rather than administering it to the resident. The nurse was also observed preparing pill packs and explaining the process to the resident's daughter, who expressed confusion about the medication packaging. The nurse denied any wrongdoing but could not account for the discrepancies in medication administration. The facility verified that the resident was not administered his prescribed narcotic as ordered and that the nurse had diverted the medication. The nurse was found to have violated the facility's code of conduct regarding drug diversion. The incident was reported to the appropriate authorities, and the nurse was subsequently terminated. The resident was considered a vulnerable adult with full capacity at the time of the incident, and the misappropriation of his medications was substantiated by both facility and external investigations.

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