Misappropriation of Resident Pain Medications Due to Medication Management Failures
Penalty
Summary
Multiple residents experienced misappropriation of their pain medications when errors were identified in the administration and documentation of narcotics. The discrepancies occurred during shifts when a specific licensed nurse had possession of the narcotic keys. The affected residents included individuals with varying levels of cognitive and physical impairment, such as those recovering from fractures, with a history of falls, or on hospice care. The errors were discovered when inconsistencies were found between the electronic medical record and the paper medication administration records, specifically regarding the logging and administration of oxycodone. Further investigation revealed that narcotics were not consistently removed from the medication cart immediately after being discontinued or when a resident left the facility, contrary to established procedures. The facility's policy required that discontinued narcotics be secured by the DON and destroyed with the pharmacist's consultation, but this process was not always followed. The breakdown in medication management led to the wrongful use of residents' medications, constituting misappropriation as defined by the facility's abuse, neglect, and exploitation policy.