Failure to Prevent and Monitor Misappropriation of Medications
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s medication when a nurse accepted and retained possession of a GLP-1 medication (Ozempic) for a male resident with type 2 diabetes and the medication subsequently could not be located. According to the facility-reported incident, the RN accepted the Ozempic from the pharmacy late at night and had it in her possession, then attempted to obtain a co-signature from an LPN after she already had the medication. The LPN found this concerning and reported it to the DON early the next morning. When first shift staff arrived, the Ozempic could not be found, and the packing slips for all medications delivered were recovered except for the Ozempic. Multiple co-workers reported that the RN frequently communicated or inquired about medications for weight loss. The facility also failed to adequately monitor and investigate potential or ongoing misappropriation of a resident’s narcotic medication when only one LPN dispensed all doses of a PRN narcotic (Norco) to a cognitively intact female resident over an extended period, and a missing tablet was documented without resolution. Review of the controlled drug records showed that from late October to early January, only one nurse dispensed the Norco, and an entry indicated a correct count had been completed but one tablet was missing and could not be accounted for. The resident reported that her pain was effectively controlled with scheduled Tylenol at night and that she did not request the PRN Norco. The DON confirmed that the pattern of only one nurse dispensing the narcotic appeared suspicious for diversion, and the NHA confirmed the resident’s report that she did not require the PRN Norco for pain control.
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