Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, specifically a narcotic pain medication prescribed for a resident with diagnoses including diabetes, depression, and chronic pain. The resident had a physician's order for Hydrocodone-Acetaminophen to be administered as needed. According to pharmacy records, a delivery of 30 tablets was made and signed for by an LPN, who reported handing the medication to another LPN responsible for the resident's medications. However, the medication was not found in the medication cart during subsequent counts, and staff interviews revealed confusion and lack of clarity regarding the medication's whereabouts. The LPN who was last reported to have received the medication left her position shortly after the incident and refused a drug screen when requested. Multiple staff members, including a QMA and several LPNs, were involved in the medication ordering, delivery, and counting process, but none could account for the missing medication. The narcotic count sheets and medication cards were reported as correct during one count, but the medication was still unaccounted for. The incident was reported to the Director of Nursing, and an investigation was initiated after it was discovered that the resident's narcotic pain medication had disappeared between the time of delivery and the next scheduled administration.