Diversion of Controlled Substances by LPN Resulting in Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation, as evidenced by the diversion of controlled medications intended for three residents. The incident involved an LPN who was observed by the DON to mishandle and ultimately divert multiple pills, including oxycodone, which were prescribed for residents with significant medical needs such as fractures, dementia, post-surgical care, and congestive heart failure. The LPN removed several controlled substances into a single medicine cup, signed them out in the controlled medication logbook, and then failed to administer them to the residents as ordered. When questioned, the LPN provided inconsistent explanations regarding the disposal of the medications and refused to allow a search of her personal belongings before leaving the facility. A review of the controlled drug logbook, medication administration records, and resident interviews confirmed that five doses of oxycodone, belonging to three residents, were signed out but not administered. The facility's investigation substantiated that the LPN diverted these medications, constituting misappropriation of resident property and exploitation. The incident was documented in a Facility Reported Incident and confirmed by the Administrator, with evidence showing that the medications were not located and the LPN was responsible for their diversion.