Failure to Prevent and Detect Misappropriation of Resident Medications
Penalty
Summary
The facility failed to implement effective systems to prevent the misappropriation of residents' medications, resulting in multiple incidents where a staff nurse diverted narcotic medications from nine residents. The diversion was discovered after a CNA reported suspicions to a supervisor, leading to an internal investigation. It was found that two nurses had suspicions of medication misappropriation but did not report their concerns to facility leadership. The nurse responsible for the diversion signed out PRN narcotic medications from the narcotic log but did not document the administration on the medication administration record for the affected residents. Despite the narcotic counts being accurate, the diversion went undetected for a period of time. The affected residents were interviewed and none reported unaddressed pain or awareness of not receiving their prescribed pain medications. The investigation confirmed that nine residents had medications diverted, but no other residents were found to be affected. The staff member responsible for the diversion had received prior education on abuse, neglect, and misappropriation of property, and had completed all required background checks. The facility's policy defined misappropriation of resident property to include medications, and the incident involved the deliberate wrongful use of residents' narcotic medications without their consent.