Failure to Prevent Misappropriation of Resident Narcotic Medications
Penalty
Summary
A deficiency occurred when a resident's narcotic pain medication, specifically Oxycodone, was diverted and unaccounted for, affecting one of three residents reviewed for narcotic pain medications. The resident involved had multiple diagnoses, including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder, and was cognitively intact. Physician orders indicated the resident was to receive Oxycodone 15 mg every six hours as needed for severe pain. Despite pharmacy records showing regular deliveries of Oxycodone, medication administration records and controlled substance inventory logs revealed significant discrepancies, with large quantities of medication unaccounted for and missing documentation. Staff statements and interviews indicated that the medication was signed into the narcotics log but not properly signed out when empty, and that the required documentation for both the administration and inventory of controlled substances was missing. Multiple staff members noted that the number of pills delivered and the number of cards and sheets signed in did not match, and that these discrepancies were not identified during shift change narcotic counts. One nurse reported that a full card of Oxycodone was missing within a week of delivery, and that the resident was left without pain medication. Additionally, there were inconsistencies in the documentation and handling of another controlled substance, Alprazolam, for a different resident, with only one card and sheet signed in for a delivery of 45 pills, when two should have been recorded. Interviews with staff and the resident confirmed that the resident did not receive pain medication as documented, and that the resident experienced significant pain and anxiety as a result. The facility's investigation was hampered by missing records, and staff reported a pattern of missing narcotics in the same hall. The facility's policy defined misappropriation of resident property as the deliberate misplacement or wrongful use of a resident's belongings without consent, and the events described in the report constitute a failure to protect the resident from such misappropriation.