Misappropriation of a Resident’s Narcotic Medication by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically narcotic pain medication, from misappropriation by staff. The facility had a policy stating residents have the right to be free from misappropriation of property and that the facility would develop and implement policies and protocols to prevent and identify theft or misappropriation. Despite this, an RN removed three 5 mg oxycodone tablets from the emergency medication kit for a resident and documented that the medication was to be given to the resident, but only one tablet was recorded as administered on the Medication Administration Record, with no documentation of the disposition of the other two tablets. Later, the RN admitted to taking an entire card of the resident’s oxycodone and folding over the narcotic count page to make it appear the medication was gone. The resident involved had multiple medical conditions, including a right femur fracture, cognitive communication deficit, major depressive disorder, osteoarthritis of the knee, seizure disorder, and chronic pain. The admission MDS showed the resident had severely impaired cognition (BIMS score of 7), limitations in all extremities, used a wheelchair, was dependent on staff for ADLs, and reported moderately rated pain. Hospital discharge orders included oxycodone 5 mg every eight hours as needed for moderate to severe pain, and the facility’s POS later reflected an order for oxycodone 5 mg every four hours as needed. Progress notes by the RN documented the resident yelling out in pain and receiving oxycodone, and referenced contacting the NP for an increased frequency order; however, the NP later stated that no such order to increase the frequency of oxycodone was given and that he/she was never notified of uncontrolled pain or yelling out in pain. The facility’s investigation found that three cards (180 tablets) of 5 mg oxycodone had been delivered for the resident and signed for by an LPN. An LPN reported that on a prior shift there had been three cards of oxycodone for the resident, but when returning to work, only two cards remained, and the narcotic count sheet page for the missing card was folded over without documentation of destruction or return. The DON stated that controlled substances were to be counted at each shift change by oncoming and off-going nurses, that counts should match the narcotic count sheets, and that staff were expected not to misappropriate resident medications. Despite these expectations and procedures, the RN’s admission to taking the resident’s oxycodone and the lack of proper documentation for removed doses demonstrated that the facility failed to protect the resident from misappropriation of property.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.