Narcotic Medication Theft by Staff Member
Penalty
Summary
The facility failed to ensure that narcotic medications were protected from theft by an employee, resulting in the misappropriation of controlled substances prescribed to two residents. One resident, with diagnoses including a pathological fracture, malignant neoplasms, osteoarthritis, and anxiety disorder, had an active order for oxycodone for pain management. Another resident, with acute pain due to trauma and multiple fractures, also had an order for oxycodone-acetaminophen for pain relief. Both residents were found to have missing narcotic medications and associated count sheets. The events leading to the deficiency involved an LPN who, during her shift, was observed on facility video surveillance removing narcotics from the medication cart, concealing them in a jacket, and subsequently placing the jacket in a bag at the nurse's station. The LPN also took the narcotic count sheet book from the cart, brought it to the locked medication room, and then returned it to the cart. The LPN left her shift early without waiting for a replacement nurse, failed to conduct a medication count with the incoming staff, and did not provide a report on the residents prior to leaving the facility. Interviews and record reviews confirmed that the missing medications were discovered when another nurse attempted to administer a pain pill and found both the narcotics and the count sheet missing. The pharmacy verified that the medications should have been available, and the incident was reported to the DON. Facility policies required shift change verification and dual staff counts of controlled substances, but these procedures were not followed, allowing the theft to occur.