Misappropriation of Controlled Substances Due to Inaccurate Narcotic Counts
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of personal property when narcotic medications were stolen or diverted for two residents. Facility policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. The policies also require that controlled substances be counted by two licensed nurses at each shift change, with both nurses verifying and signing off on the count. Despite these policies, a discrepancy was identified involving missing narcotic medications for two residents, with the loss discovered during a medication count by nursing staff. One resident, admitted with diagnoses including viral hepatitis, rhabdomyolysis, and pulmonary fibrosis, was prescribed Suboxone for opioid withdrawal and experienced frequent pain. The medication administration record showed that Suboxone was not available for a scheduled dose, and the medication was not administered as ordered. Another resident, admitted with an amputation and prescribed oxycodone for pain, was discharged from the facility, but a review of records revealed missing oxycodone tablets. The missing medications were identified after a shift change count, which initially appeared accurate but was later found to be manipulated. Interviews and documentation revealed that an agency nurse manipulated narcotic count sheets, resulting in inaccurate medication counts and the loss of controlled substances. The facility's investigation confirmed that a total of ten oxycodone tablets and nine Suboxone pills were missing. The incident involved the manipulation of records and failure to maintain accurate control and documentation of narcotic medications as required by facility policy.