Failure to Prevent Drug Diversion of Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the diversion of approximately 23 tablets of Hydrocodone, a controlled narcotic medication. The resident, who had diagnoses including end stage renal disease requiring dialysis, dyspnea, hyperkalemia, fluid overload, and pain, was prescribed Hydrocodone-Acetaminophen for pain management. The medication was documented as missing from the medication cart, along with the corresponding narcotic log, during a routine medication administration. Multiple staff statements indicated that the medication and log were present during previous shift counts, but were later discovered missing, and no staff could account for their disappearance. The facility's investigation included reviewing staff statements, drug testing all staff who had access to the medication cart, and auditing medication carts and logs. Staff involved in the medication management process denied diverting the medication and all tested negative for controlled substances. The missing medication and narcotic log were never recovered, and the facility was unable to determine how the medication was diverted or who was responsible. The pharmacy confirmed delivery of the medication, and the resident did not miss any doses, as another blister pack was available and used for administration. The resident was out of the facility on leave when the diversion was discovered and reported that he had not missed any doses of his pain medication. Staff interviews and record reviews confirmed that the resident's pain management was not interrupted, and he expressed feeling safe and having no concerns about medication administration. The facility's policies required strict accounting and shift-to-shift counting of controlled substances, but the failure to prevent the diversion of the resident's medication and the associated narcotic log constituted a failure to protect the resident from misappropriation of property.