Narcotics Misappropriation Due to Inadequate Documentation and Security
Penalty
Summary
The facility failed to protect residents from misappropriation of property when narcotics belonging to two residents were unaccounted for. A discrepancy was identified on the Controlled Drug Count Sheet, with numbers scratched out and rewritten, resulting in a two-card difference. The narcotic count dropped from 34 to 31 packages/sheets without documentation of removal, and the Master List Controlled Drug form for a specific period was missing. One resident's discontinued Norco medication remained on the cart, and another resident's active Norco was also unaccounted for. Staff interviews confirmed that narcotics are supposed to be reconciled each shift, but the process was not properly followed, and documentation was incomplete or altered. The Director of Nursing confirmed that the missing narcotics were not accounted for and that the Master List Controlled Drug form could not be located. The nurse on duty during the shift in question refused to assist with the investigation and was subsequently suspended and terminated. The facility's policy required residents to be free from misappropriation of property, but the failure to properly document, reconcile, and secure narcotics led to the loss of controlled substances belonging to two residents. The residents involved had diagnoses of hypertensive disease without heart failure and cerebral infarction, respectively.