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F0602
D

Misappropriation of Narcotic Medication by Staff Member

Hamden, Connecticut Survey Completed on 12-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a staff member, specifically an agency LPN, removed a narcotic medication, oxycodone 5 mg, from the medication cart for personal use, violating facility policy and procedures. The incident involved a resident with diagnoses including generalized abdominal pain, interstitial pulmonary disease, chest pain on breathing, and anxiety, who was alert and oriented. The resident had a physician's order for oxycodone 5 mg to be administered as needed for pain, and the medication was documented as received and partially administered prior to the incident. On the day of the incident, the LPN arrived late for her shift and did not participate in the required narcotic count with the outgoing nurse, instead taking the keys without following protocol. Throughout her shift, surveillance footage captured the LPN engaging in suspicious behavior around the medication cart, including handling the narcotic log binder out of camera view, shuffling papers, and being observed placing medication cups to her mouth on multiple occasions. The narcotic count logs were found to have been altered, and a significant quantity of oxycodone tablets, along with the disposition record, went missing from the cart and could not be located despite a thorough search. Interviews with staff confirmed that the required two-nurse narcotic count was not performed at shift change, and that the LPN in question appeared anxious and fidgety during her shift. The DON and other staff members identified discrepancies in the narcotic count and documentation, and the LPN was observed ingesting medication at the cart. The facility's abuse prohibition policy, which defines misappropriation of resident property as the wrongful use of a resident's belongings without consent, was not followed in this instance, resulting in the misappropriation of the resident's narcotic medication.

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