Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property, specifically related to missing medication. According to the facility's abuse prohibition policy, misappropriation includes the wrongful use of a resident's belongings without consent. In this case, a resident with diagnoses including cancer and chronic pain, who was prescribed oxycodone for pain management, was affected when 30 tablets of oxycodone were found to be missing from the narcotic drawer. Review of documentation showed that the medication was delivered to the facility and was present in the narcotic drawer, as confirmed by inventory count sheets and pharmacy shipping records. During a series of shift changes, discrepancies in the narcotic count were noted. Employee E7, a licensed nurse, and Employee E8, an agency licensed nurse, were responsible for the medication cart during the relevant shifts. The count sheets indicated inconsistencies, including missing signatures and a lack of proper documentation at the end of Employee E8's shift. Employee E7 discovered the missing medication during her shift and reported it immediately to her supervisor. Interviews confirmed that the controlled drug procedures were not followed, leading to the loss of the medication. The Director of Nursing verified that the medication was not found in the facility and had to be replaced. Employee E8, who was identified as the alleged perpetrator, did not respond to requests for an interview. The incident was reported to the Pennsylvania Department of Health, and the facility was found to be noncompliant with regulations regarding management, pharmacy services, and nursing services.