Failure to Account for Controlled Medication Resulting in Missing Lorazepam Tablets
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by not ensuring proper accountability of controlled medications. Facility policies required that controlled substances be counted at each shift change by two licensed nurses, with any discrepancies reported to the DON, and that a physical inventory of all controlled medications be conducted and documented at each shift change. The Abuse Prevention policy defined misappropriation of resident property as the wrongful use of a resident’s belongings without consent. For one resident with severe cognitive impairment (BIMS score of 0), admitted with moderate protein-calorie malnutrition, dementia, adult failure to thrive, and receiving medications via g-tube, hospice was consulted and lorazepam and morphine were ordered for end-of-life comfort care. According to the record and interviews, a hospice RN obtained 15 lorazepam 0.5 mg tablets from the contracted pharmacy in a brown pill bottle for the resident. An LPN and an SRNA/KMA counted 15 tablets, created a narcotic count sheet, and locked the bottle in the narcotic drawer of the medication cart. The LPN administered one dose of lorazepam via g-tube later that day, leaving 14 tablets. The SRNA/KMA reported that the evening was hectic due to a call-in and stated that at shift change, she informed the oncoming LPN that the lorazepam was in a bottle rather than a blister pack, but the oncoming LPN closed the drawer without counting the pills. The SRNA/KMA further stated that the following morning she failed to count the lorazepam bottle with the night shift nurse before accepting the cart keys, despite knowing facility policy required this. Later that day, when the LPN went to administer another dose of lorazepam to the resident, only nine tablets were found in the bottle instead of the expected 14, indicating five missing tablets. The LPN and SRNA/KMA recounted and confirmed the discrepancy, then attempted to locate the DON and, when unsuccessful, reported the missing tablets to the unit manager RN. The pharmacist confirmed that 15 lorazepam tablets had been dispensed in a brown bottle to the hospice RN. The responding police officer reported being contacted by the Administrator and noted that key staff had been sent home or were unavailable, and that no police report had yet been filed at the time of interview. The DON and Administrator both stated they expected all narcotics to be thoroughly counted at cart acceptance regardless of container type, but the required counts and documentation were not consistently performed, resulting in unaccounted-for controlled medication for the resident.
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