Failure to Prevent Misappropriation of Resident's Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of property, specifically regarding the administration and documentation of the resident's prescribed Oxycodone. The resident, who had diagnoses including fibromyalgia and low back pain, was on a scheduled opioid regimen and was cognitively intact, independently managing aspects of her care and regularly counting her medications. On the date in question, records showed that six doses of Oxycodone were documented as administered, despite only five being scheduled. Discrepancies were noted between the individual control drug record and the electronic medication administration record (eMAR), with the control record reflecting an extra administration that was not corroborated by the eMAR or the resident's own account. Multiple staff members, including medication aides and nurses, identified and reported the irregularity in the narcotic count and documentation. The nurse responsible for the extra entry could not provide a clear explanation, alternately stating she may have given an extra dose or simply documented the wrong time. The resident denied receiving an extra dose and consistently counted her pills before taking them. The incident was reported up the chain of command, and interviews with staff indicated concerns about the nurse's behavior and the possibility of drug diversion, though the nurse was not immediately suspended for this incident. The facility's own policies defined misappropriation of resident property as the wrongful use of a resident's belongings, including medications. The documentation and interviews confirmed that a dose of the resident's Oxycodone was unaccounted for and could not be reconciled through resident or staff accounts, nor through medication records. The failure to ensure accurate administration and documentation of controlled substances resulted in the misappropriation of the resident's medication.