Failure to Prevent Diversion of Controlled Substance by Agency Nurse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of property, specifically the diversion of the resident's prescribed Hydrocodone 10/325 medication. The resident, a male with a history of anxiety disorder, depression, and diabetes mellitus, had a physician's order for Hydrocodone-acetaminophen to be administered as needed. The medication was properly received and added to the controlled substance count, but after the resident returned from a hospital stay, it was discovered that the medication and its count sheet were missing from the medication cart. On the day prior to the discovery, an agency LVN was observed to have spilled water in the narcotic drawer of the medication cart. The DON and MDS Coordinator conducted a narcotic count following this incident and found all cards and pills accounted for, including the resident's Hydrocodone. However, the next day, when the resident returned and requested pain medication, staff found that both the medication cards and the count sheet for the Hydrocodone were missing. The incident was reported to facility management, and an internal investigation confirmed that the medication had been diverted during the agency LVN's shift. Interviews with staff revealed that standard procedures required counting both the cards and pills for controlled substances at each shift change, and that any discrepancies were to be reported immediately. Despite these procedures, the medication was able to be removed without detection until the resident returned and the need for the medication was identified. The agency LVN suspected of diverting the medication did not respond to attempts to contact her after the incident.