Failure to Prevent and Monitor Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for multiple residents, as evidenced by altered documentation and unaccounted-for doses of narcotic medications. For one resident, the Controlled Substances Proof of Use sheet showed repeated alterations in the quantity remaining, with bold overwriting of numbers to obscure previous entries. This resulted in discrepancies where more tablets were dispensed than ordered, and the documentation was manipulated to hide the actual count. Staff interviews confirmed that an agency LPN was responsible for altering the narcotic count and that these changes were not immediately detected during shift exchanges, as the counts were verbally confirmed rather than visually verified against the medication sleeves and documentation. Another resident's records revealed that an additional dose of a controlled medication was dispensed outside of the prescribed times, with no corresponding entry in the electronic medication administration record (eMAR) or the resident's electronic medical record. The missing documentation and the lack of a scheduled administration at that time indicated that the medication was unaccounted for. Further audits of medication carts did not reveal additional discrepancies, but the incident was substantiated as misappropriation based on the available evidence. Staff statements indicated that the LPN involved had a history of similar issues at other facilities. Additional deficiencies were identified for other residents, including the dispensing of controlled substances without active orders, administration of medications outside of prescribed times, and lack of required documentation for medication administration and wastage. In several cases, doses were dispensed and not recorded in the eMAR, and there was no second nurse signature to verify wastage of unused medication. Interviews with nursing staff and review of facility policies confirmed that these actions did not follow professional standards or facility procedures for controlled substance management, leading to unaccounted-for medications and the potential for ongoing diversion.