Misappropriation of Narcotic Medication by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medications. A licensed practical nurse (LPN) signed out additional doses of Hydrocodone-Acetaminophen for a resident who was prescribed this medication for chronic pain related to osteoarthritis, but there was no physician order for extra or PRN doses. The medication administration record showed the resident only received the scheduled doses, and there was no documentation that the resident received the additional doses signed out by the LPN. The resident's pain scores on the relevant days indicated minimal pain, and the resident later reported no concerns regarding pain medication administration. The misappropriation was discovered when a registered nurse (RN) noticed discrepancies during a narcotic count and reported the issue to the Assistant Director of Nursing (ADON). An audit by the Pharmacy Nurse Consultant confirmed that extra doses had been signed out for the resident, but not administered. The LPN admitted to signing out and taking the extra medication for personal use. The facility's policy requires oversight to prevent misappropriation of resident property, but the LPN was able to divert narcotic medication by signing out extra doses without detection until the audit and count revealed the discrepancy. Interviews with staff and review of documentation confirmed that the resident did not miss any scheduled doses and did not experience harm as a result of the incident. The misappropriation was limited to the LPN signing out and diverting narcotic medication intended for the resident, in violation of facility policy and resident rights. The incident was reported to appropriate authorities, and the facility's failure to prevent this misappropriation constituted a deficiency under F-602.