Misappropriation of Controlled Substance for Hospice Resident
Penalty
Summary
A resident was admitted to the facility and placed on hospice care, with a physician order for Morphine Sulfate to be administered as needed for pain or shortness of breath. The controlled substance record indicated that a 5ml bottle of Morphine Sulfate was received for the resident, but the Medication Administration Record showed that no doses were administered and the resident had no complaints of pain. A nurse noticed that the Morphine bottle appeared unusual, with a thick gel and pink color, and later discovered that both the bottle and the count sheet were missing. The count sheet was later found intact in the shred bin, with no doses signed out, and the master count sheet did not reflect the medication being signed out. The Director of Nursing conducted a review, including video footage of shift change narcotic counts, and determined that the bottle and count sheet were last seen during a morning count between two nurses. The subsequent shift change was not visible on camera, and the nurse who participated in the count did not recall seeing the Morphine bottle. Based on these findings, it was determined that a nurse had taken the bottle of Morphine, resulting in the misappropriation of the resident's medication. The facility's policy defines misappropriation as the deliberate misplacement or wrongful use of a resident's property without consent.