Failure to Prevent Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to ensure the right to be free from misappropriation of property for a resident who was prescribed Soma, a muscle relaxant. The resident, a severely cognitively impaired female with multiple diagnoses including congestive heart failure, schizoaffective disorder, panic disorder, dementia, diabetes, and chronic pain, was unable to make decisions and required assistance from two staff members for activities of daily living. Despite having a physician's order for Soma 325mg to be administered three times daily and at bedtime, it was discovered that 11 Soma tablets were missing from her blister pack. The medication administration record indicated that no doses were missed during the relevant period, and the pharmacy manifest confirmed delivery of the correct quantity of medication. The deficiency was identified when staff noticed discrepancies in the medication count sheets, including numbers that had been written over and skipped, as well as signatures at times when the nurse was not assigned to the resident. Interviews with staff revealed that the count was correct at one point, but later counts did not match the actual number of pills present. The count sheet for the Soma had been altered from one date to another, and the missing medication could not be located after checking medication carts, rooms, and other areas. One agency nurse who had access to the medication during the relevant period could not be reached for an interview despite multiple attempts by facility staff, the agency, and the police. The resident was unable to provide information due to confusion and forgetfulness. The facility's abuse prevention policy states that residents have the right to be free from misappropriation of property. The investigation involved notifying the police, the family, the pharmacy consultant, and the medical director, but the facility was unable to confirm who was responsible for the missing medication.