Failure to Prevent and Report Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled narcotic medications for two residents. One resident, with diagnoses including dementia, dysphagia, amputation, and osteoarthritis, had a physician's order for liquid Morphine Sulfate as needed for pain or shortness of breath. Despite the medication being present in the facility for several months, there was no documentation of any doses being administered, and a discrepancy was discovered when a nurse noted that the Morphine bottle contained less medication than expected. The bottle was found to have a puncture hole in the seal, and the syringe packaging was unused, indicating the medication had been accessed without proper documentation. A similar puncture was found in another resident's Morphine bottle, which appeared full but was later determined to have a diluted concentration of the drug, suggesting tampering and replacement of the medication with another solution. Further investigation into the second resident revealed that a standing order for Morphine Sulfate was not properly carried over into active physician's orders, resulting in the medication not being included on the medication administration record. The controlled drug record for this medication was blank, showing no evidence of administration. Additionally, the same resident had an order for Oxycodone, and an internal investigation found that multiple Oxycodone tablets had been removed from blister packs and replaced with Loratadine tablets. The tampering was confirmed by the facility's contracted pharmacist, who identified slits in the blister pack backing and mismatched tablets. The investigation could not determine who was responsible for the tampering, but it was clear that the resident did not receive the intended medication. The Director of Nursing (DON) did not initially report these incidents to the state survey agency, believing that reporting was only required if misappropriation was proven. However, the facility's own policy required immediate reporting of any allegations or suspicions of misappropriation. The DON later acknowledged that the incidents should have been reported in a timely manner, as required by policy and regulation. The findings were confirmed by the Ohio Board of Pharmacy, which conducted on-site investigations and confiscated the tampered medication bottles and blister packs.