Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property, specifically regarding the loss of prescribed narcotic medication. The resident, who had a history of left knee replacement, obstructive sleep apnea, and morbid obesity, was assessed as cognitively intact with a BIMS score of 13. The resident had physician orders for Oxycodone HCL and Tylenol Extra Strength for pain management. According to medication administration records, the resident received multiple doses of both medications during the review period. On the night in question, two RNs were responsible for the medication cart containing the resident's narcotic medication. The narcotic count was verified as correct during shift changes. However, during an early morning medication request, one RN was unable to locate the Oxycodone card or the associated narcotic tracking sheet in the medication cart. Further investigation revealed that the original tracking sheet had been removed and replaced with a new one, and the missing count signoff sheet was later found unsigned in the recycle bin. The missing Oxycodone and its documentation were not recovered, and the resident experienced a delay in receiving pain medication as a result. Staff interviews and documentation confirmed that only the two RNs had access to the medication cart during the relevant period. There was no evidence that the resident was interviewed regarding the missing medication, and the facility was unable to identify a perpetrator. The incident was reported to the local police department. The deficiency was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to protect the resident from misappropriation of property.