Failure to Account for and Properly Document Destruction of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of property when staff could not account for two residents' controlled medication cards containing narcotics that were in the facility's possession. The missing medications were oxycodone/acetaminophen tablets, each card containing 30 tablets, prescribed for pain management. Documentation showed that the medication cards were marked as destroyed on narcotic count sheets, but there was no evidence or witness to the destruction, and the destruction log binder did not contain the required destruction sheets for these medications. Interviews and record reviews revealed that the former DON and a Certified Medication Technician (CMT) signed off on the destruction of the medications, despite both stating they did not actually destroy the medications. The CMT reported being asked by the former DON to sign the narcotic sheet, with the understanding that the matter was taken care of, but did not witness or participate in the destruction. The former DON admitted to incorrectly marking the medications as destroyed on the narcotic sheets, stating she was not trained as a DON and believed it would be wrong to write 'missing' or 'stolen.' Multiple staff interviews confirmed that the medications were not destroyed and that the required procedures for handling, counting, and documenting controlled substances were not followed. Both residents involved had documented needs for pain management and were receiving scheduled opioid medications for chronic pain conditions. The facility's policies required strict procedures for the handling, counting, and destruction of controlled substances, including dual signatures and proper documentation, none of which were followed in these cases. The failure to account for the controlled medications and the improper documentation constituted misappropriation of resident property.