Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A resident with dementia was admitted to the facility for rehabilitation following surgical repair of a fractured femur. Upon admission, the resident was prescribed Oxycodone 5 mg every six hours as needed for pain and Acetaminophen 500 mg on a scheduled basis. Pharmacy records confirmed that 28 tablets of Oxycodone were delivered to the facility and received at 4:20 AM. However, documentation on the controlled drug receipt record showed discrepancies, including the initial count being marked as 26 tablets instead of 28, and multiple doses being signed out at times before the medication was actually delivered. Nurse documentation indicated that two tablets were removed at each administration, despite the order being for one tablet, and that four tablets were signed out prior to the medication's arrival at the facility. The nurse responsible could not provide a satisfactory explanation for these discrepancies, and there was no record of Oxycodone being removed from the facility's backup supply for the resident. The inconsistencies were identified by another nurse during a shift change and subsequently reported to the acting DON, who verified the discrepancies with the pharmacy and reviewed the documentation. Interviews with staff and pharmacy confirmed that the medication counts and documentation did not align with the actual delivery and administration records. The nurse involved was suspended and later terminated, and the incident was reported to the appropriate regulatory and law enforcement agencies. The facility's failure to accurately account for and protect the resident's controlled medication resulted in a deficiency related to misappropriation of resident property.