Failure to Prevent Misappropriation of Controlled Medications by LPN
Penalty
Summary
The facility failed to protect six residents from misappropriation of medications by a Licensed Practical Nurse (LPN), as evidenced by video surveillance, medication reconciliation records, and staff interviews. Over the course of a night shift, the LPN was observed on camera removing medications, including controlled substances such as oxycodone, pregabalin, lorazepam, morphine, diazepam, and Norco, from medication drawers and narcotic boxes. The LPN was seen dispensing medications into her bare hands, placing them into cups, and at times putting items into her mouth or her clothing. At no point was the LPN observed referencing the Electronic Medication Administration Record (EMAR) while handling these medications. Record reviews revealed that the LPN removed additional doses of medications for six residents without documenting administration in the residents' MARs or the narcotic reconciliation system. In several cases, the medications were not administered to the residents as ordered, and there was no documentation to support that the residents received their prescribed doses. One resident reported not receiving pain medication, despite the MAR indicating it had been signed out, and accepted alternative pain relief. Staff interviews confirmed that the only way to verify medication administration is through proper documentation, and discrepancies were identified when reviewing the narcotic reconciliation system and MARs. The facility's investigation, supported by video evidence and staff statements, established that the LPN diverted medications intended for residents, including controlled substances, and failed to follow required documentation and administration protocols. The facility's policies require that the dose noted in the usage form or automated dispensing system must match the dose recorded in the MAR and other records, which was not adhered to in these instances. The misappropriation was reported to local authorities for further investigation.