Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of narcotic medications for two residents. Both residents had physician orders for opioid pain medications, which were delivered to the facility and documented as administered according to their Medication Administration Records. However, it was later discovered that one medication card containing 30 tablets for each resident was missing and could not be located within the facility. The issue was identified when a nurse noticed a discrepancy in the narcotic medication card count during her shift. She recalled that the number of narcotic cards had decreased unexpectedly and questioned another nurse, who denied removing any narcotics. After further investigation and a search of the medication cart, it was confirmed that the medication packs and their corresponding countdown sheets for both residents were missing. The facility's pharmacist confirmed the delivery process and the expectation for the facility to notify the pharmacy of any discrepancies, which was done after the issue was identified. Interviews with staff involved in the medication administration and narcotic count process revealed that the missing narcotics were not accounted for by any of the nurses on duty. The nurse who was named in the investigation as potentially involved was placed on a do not return list, but attempts to interview her were unsuccessful. The facility was unable to substantiate the allegation internally, but the missing narcotics were confirmed as removed from the facility and reported to the appropriate authorities.