Failure to Protect Residents from Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled substance medications, specifically oxycodone, prescribed for pain management. Two residents with chronic pain and other significant medical conditions were affected. For one resident, a physician's order for oxycodone was received and the medication was delivered and documented as administered on several occasions. However, the controlled drug record, which should have documented each withdrawal of the medication, was missing, and a significant number of tablets could not be accounted for. For the second resident, multiple deliveries of oxycodone were documented, but the corresponding controlled drug records for these deliveries were also missing, and a large quantity of tablets was unaccounted for. The events leading to the deficiency included the discovery by nursing staff that the bubble pack cards containing oxycodone and their corresponding controlled drug records were missing from the medication carts. Staff interviews confirmed that the medications were present and administered as ordered on previous shifts, but were later found to be missing. The facility's investigation identified a specific nurse who had access to the medication carts during the relevant shifts and was subsequently unable to be contacted after being suspended pending investigation. The missing medications were not found despite comprehensive searches and audits of medication carts and records. The affected residents did not report missing any doses of their pain medication, as alternative pain management was provided and replacement medications were obtained. The facility's records and staff interviews confirmed that the missing medications were as-needed (PRN) and had not been requested by the residents prior to the discovery of the discrepancy. The total number of missing oxycodone tablets between the two residents was determined to be 91, with no documentation or explanation for their disappearance.