Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of residents' property, specifically controlled narcotic medications, for three residents with intact cognition and chronic pain conditions. For one resident with fibromyalgia and depression, records indicated that a dose of narcotic pain medication was documented as administered by an LPN, but the resident reported not receiving it, and video footage confirmed the LPN did not enter the room at the documented time. The resident confirmed the last dose received was the previous night, and the nurse had not provided the pain medication as recorded. Another resident with rheumatoid arthritis had narcotic pain medication documented as administered by the same LPN on two occasions. However, video footage showed the LPN did not enter the resident's room during the relevant timeframes, and the resident's written statement confirmed no pain medication was requested or received during those shifts. The medication administration record also lacked documentation for one of the doses. A third resident with Parkinson's disease and chronic pain had multiple doses of narcotic pain medication signed out as administered by the LPN. Video review revealed that, except for one instance where the LPN entered the room with a medication cup, the LPN did not enter the resident's room at the times the medication was documented as given. These findings demonstrate that the facility did not ensure residents' medications were administered as ordered and documented, resulting in the misappropriation of controlled substances.