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F0602
D

Misappropriation of Resident Medications by CMT

Saint James, Missouri Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to prevent the misappropriation of medications for two residents. A Certified Medication Technician (CMT) was found to have signed out and documented the administration of Lorazepam to both residents without proper authorization or, in some cases, after the medication had been discontinued by the physician. For one resident, the CMT continued to sign out and document administration of Lorazepam even after the physician had discontinued the order, and for the other resident, the CMT signed out and documented doses that were not present in the medication cup at the time of administration. These actions were discovered following a report from a Certified Nurse Aide (CNA) who had evidence of the CMT stealing medications, prompting an immediate narcotics count by the Director of Nursing (DON). The review of medication administration records, controlled drug receipt forms, and physician orders revealed discrepancies between the medications signed out and those actually administered or present. The CMT had pre-popped medications and falsified records to indicate administration that did not occur, resulting in the wrongful use and misappropriation of resident medications without consent. Both residents involved had documented needs for or histories of antianxiety medication, with one assessed as moderately cognitively impaired and the other as cognitively intact.

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