Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of controlled medications, specifically liquid lorazepam prescribed for comfort care. During a shift exchange, a nurse observed another nurse taking possession of a medication cup containing liquid, stating it was for later use for a specific resident. Upon further investigation, facility leadership discovered a bottle of liquid lorazepam with an unusual pink tint, which was confirmed by pharmacy staff to have been tampered with, as the medication should be colorless. The tampered bottle was immediately removed from circulation. The resident involved was nearing the end of life and receiving comfort care, with physician orders for as-needed administration of liquid lorazepam for generalized anxiety disorder. Medication administration records indicated the resident received the medication as ordered during the period in question, and there was no documentation or interview evidence suggesting the resident did not experience relief from symptoms. The incident was reported and investigated after staff observed irregular handling and storage of the controlled medication.