Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure the right to be free from misappropriation of resident property for two residents, resulting in the diversion and loss of controlled medications. For one resident with multiple sclerosis, ADHD, PTSD, and anxiety disorder, approximately 25 tablets of Amphetamine-Dextroamphetamine were reported missing. The medication count sheets and narcotic substance records were found to be tampered with, including scratched-out and overwritten numbers, and the corresponding blister packs could not be located. Staff interviews and record reviews confirmed that the medication was present and accounted for at the end of one shift, but discrepancies were discovered after the subsequent shift, during which a specific nurse had access to the medication cart and documentation. A second incident involved another resident with chronic pain syndrome, osteoarthritis, and hemiplegia, for whom 57 tablets of Hydrocodone-Acetaminophen (Norco) were reported missing. The narcotic count sheet for this medication was also found to be altered, with evidence of white-out and overmarking to make the count appear correct. The pharmacy confirmed the delivery of the correct quantity of medication, but the facility discovered the discrepancy when a refill was requested earlier than scheduled. The missing medication and altered documentation were linked to the same nurse who had access to the medication cart during both incidents. In both cases, the residents did not miss any doses of their prescribed medications, and there were no reports of unrelieved pain or missed treatments. However, the facility's failure to prevent the misappropriation of controlled substances and the tampering of medication records constituted a violation of residents' rights and facility policy. The investigation did not identify eyewitnesses to the theft, but the documentation and timing of the discrepancies pointed to a single staff member who had access during the relevant periods.