Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medication, specifically methadone prescribed for pain management. The resident, who was cognitively intact and had a history of diabetes with polyneuropathy and chronic pain, was admitted with an order for methadone 10 mg three times daily. During a leave of absence, the facility sent a supply of methadone with the responsible party, and medication counts were maintained on count sheets. However, upon reconciliation of medications after the resident's discharge, it was discovered that one card of methadone and its corresponding count sheet were missing. The discrepancy was identified when a refill request for methadone was denied by the pharmacy for being too soon, prompting the nurse practitioner to notify the DON of possible drug diversion. Investigation revealed that after the last documented administration from one card, the next card and its count sheet were missing, and staff had begun using a subsequent card. The end-of-shift narcotic count appeared correct because both the medication card and count sheet were absent, masking the loss. The nurse who last handled the medication stopped coming to work once the investigation began and was subsequently terminated. Interviews with the resident confirmed she received her medication as ordered and did not experience uncontrolled pain. The pharmacy and pharmacy supervisor confirmed the facility attempted to refill the medication prematurely and that no methadone had been returned. The incident was reported to law enforcement, and the facility initiated an internal investigation. The deficiency centers on the facility's failure to prevent the misappropriation of a resident's narcotic medication, as required by policy and regulation.