Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medications, specifically Oxycodone, for two residents. For one resident, physician orders indicated a prescription for Oxycodone 5 mg twice daily, with two medication cards of 30 tablets each delivered to the facility. However, during a routine narcotic count, staff discovered that one of the medication cards was missing from the locked narcotic box in the medication cart. The medication administration records showed the resident consistently received the prescribed doses and did not report pain, but the missing card was not accounted for, and the receiving nurse had not signed the pharmacy delivery slip. For another resident, who had a PRN order for Oxycodone 5 mg, a medication card of 28 tablets was found missing from the locked narcotic drawer. The resident rarely used the Oxycodone due to an alternative prescription for liquid Morphine Sulfate, and the medication administration record confirmed no doses had been administered. The discrepancy was identified during a narcotic count conducted by a medication aide and a hospice nurse, who noted the absence of the medication card that had previously contained 28 tablets. Interviews with staff revealed that narcotic counts were not consistently performed according to facility policy, and documentation of the number of medication cards was incomplete on several occasions. The pharmacy was not notified of the missing medications, and staff involved in the counts were not suspended or drug tested during the investigation. The facility was unable to determine who was responsible for the missing narcotic medication cards.