Controlled Substance Diversion and Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect residents' rights and ensure proper management of controlled substances, resulting in the misappropriation of medications intended for two residents. Specifically, a Licensed Vocational Nurse (LVN) diverted controlled medications prescribed for two residents for personal use and failed to document and discard discontinued medications according to facility policy. The LVN removed two bubble packs of oxycodone, each containing 30 pills, from the controlled substance drawer after a resident's discharge, documented a zero count in the inventory log, and removed the corresponding record sheet, making the medication untraceable. This action was discovered during a shift change audit when the missing medications were identified, and the LVN later admitted to taking the medications. The facility's procedures required that discontinued controlled substances be handed off to the Director of Nursing (DON) for proper destruction, but this protocol was not followed. In another instance, the same LVN signed out multiple doses of hydrocodone-acetaminophen for a second resident on the controlled drug record, but these administrations were not documented on the Medication Administration Record (MAR). The resident had moderate cognitive impairment and was prescribed pain medication as needed. The discrepancies were identified after the initial drug diversion incident, revealing that the medications were not administered as ordered and were unaccounted for. The facility's policy required daily visual audits of controlled substances, but the DON only conducted these audits Monday through Friday, leaving weekends unmonitored until the following Monday. Both residents involved had significant medical histories, including chronic pain, recent surgery, and cognitive impairment, making the proper administration and accountability of their medications critical. The failures in following established protocols for controlled substance management, documentation, and destruction led to residents not receiving their prescribed medications as ordered and placed them at risk for inadequate pain management and anxiety. The facility's lack of adherence to its own policies and procedures directly contributed to the deficiency.