Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including cerebrovascular disease, chronic pain syndrome, and diabetes, was not protected from the misappropriation of his prescribed Oxycodone medication. The resident was cognitively intact and had a physician's order for Oxycodone 5 mg at bedtime. Documentation showed that a new card of thirty Oxycodone tablets was received and added to the medication cart, and one tablet was administered each evening for seven days. However, on a subsequent shift, the controlled substance inventory count sheet indicated the card was removed from the cart as empty, but only one nurse had signed the sheet, contrary to facility policy requiring two signatures for such removals. Further review of the Medication Administration Record (MAR) revealed that on several dates following the removal, the resident did not receive his Oxycodone due to the medication being unavailable, and on one occasion, a muscle relaxer was given instead. The resident reported no pain during these times. The facility was unable to locate the controlled substance count sheet for the removed Oxycodone, and it was recognized that approximately 23 tablets were missing. The Director of Nursing confirmed that the required procedures for controlled substance accountability were not followed, as only one nurse signed for the removal of the narcotic card, and the medication card was found partially shredded. Interviews with the resident and staff confirmed the medication was taken by a nurse, and the administration was aware of the situation. The nurse responsible for the single-signature removal was suspended pending investigation and later resigned. Facility policy required that controlled medications be counted with another designated staff member during key exchanges and that discrepancies be resolved before the off-going nurse leaves, but these procedures were not followed in this incident.