Misappropriation and Substitution of Controlled Medication
Penalty
Summary
A facility failed to protect a resident's right to be free from misappropriation of controlled medications when it was discovered that seven oxycodone tablets, prescribed as needed for pain, were removed from the resident's medication card and replaced with similar-looking Buspirone tablets. The tampering was first noticed by a nurse who, upon responding to the resident's request for pain medication, observed that the pills in the card did not match the expected appearance of oxycodone. Further inspection revealed that the back of the medication card had been incised and taped closed, and the substituted pills were identified as Buspirone, a medication previously discontinued for the resident. The medication administration record showed that the last documented administration of oxycodone was by a nurse who could not be reached for follow-up. The incident was reported internally after the discovery, and it was confirmed that the resident did not miss any prescribed doses of pain medication, as the medication was ordered on an as-needed basis and the resident rarely requested it. The investigation included interviews with multiple staff members, review of medication records, and confirmation that the resident's insurance was initially billed for the replacement oxycodone, which was later corrected to bill the facility instead. Interviews with staff and pharmacy personnel confirmed the misappropriation and substitution of the controlled medication. Drug tests were administered to staff who had access to the medication cart, and both tested positive for oxycodone. The resident reported that she received pain medication when requested and did not experience unaddressed pain. The facility's investigation did not substantiate abuse or neglect, but the misappropriation of controlled substances was clearly documented through observations, interviews, and record reviews.