Misappropriation of Controlled Medication for a Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications. A cognitively intact resident with chronic pain syndrome had an active order for Oxycodone 5 mg, both scheduled and as needed. On a morning medication pass, a medication aide discovered that the resident's narcotic medication card and controlled drug count sheet were missing from the medication cart, despite the narcotic count being correct at the previous shift change. The missing items were reported immediately, and an internal investigation was initiated. Interviews with staff who worked the relevant shifts revealed that none recalled removing the medication card or count sheet. The investigation determined that 53 tablets of Oxycodone 5 mg were missing and could not be located anywhere in the facility. The nurse who had access to the medication cart during the relevant period did not return to work and could not be reached for interview. The pharmacy confirmed that the facility reported the missing narcotics and that the resident continued to receive pain medication as ordered, with no interruption in pain management. The incident was substantiated as misappropriation of resident property, specifically controlled medication. The facility reported the event to appropriate authorities, including the Department of Health and Human Services, law enforcement, and the state nursing board. The resident involved reported no concerns with pain management and was assessed with no adverse consequences noted at the time of the incident.