Medication Diversion by Staff Member
Penalty
Summary
The facility failed to protect the medications of two residents from diversion by a staff member, resulting in a deficiency. One resident, admitted with malignant neoplasm of the vulva, rheumatoid arthritis, and chronic pain syndrome, was receiving hospice care and had an order for Oxycodone to be administered as needed for pain. Another resident, admitted with acute kidney failure, type 2 diabetes, and essential tremor, had an order for Metformin to be administered twice daily. Both residents were cognitively intact according to their BIMS scores. The incident was discovered when a staff member noticed that the controlled substance sheet and the bottle of Oxycodone for the first resident were missing from the medication cart. A review of security footage revealed that a staff member was observed counting medications alone at the narcotic cart, removing a bottle with a red top (indicating a narcotic), and subsequently taking the bottle down the hallway and returning without it. The same staff member was also seen taking the narcotic sheet and placing it in his backpack, as well as taking a pill from a bottle and ingesting it. The staff member later admitted, via text message, to taking another resident's Metformin as well. Interviews with nursing staff confirmed that controlled medications are to be counted by both the oncoming and outgoing nurses together, and that taking medications not intended for administration is inappropriate and constitutes diversion. The facility's policy on controlled substances requires that discrepancies be reported to the Director of Nursing and that counts be reconciled at the end of each shift by two nurses. The staff member involved was observed acting alone, removing medication and documentation, and ingesting a controlled substance, all in violation of facility policy and procedure.