Misappropriation of Controlled Narcotics and Inadequate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled narcotic medications, contrary to its Abuse, Neglect and Exploitation policy that prohibits exploitation and misappropriation of resident property. An agency nurse (Nurse #1) worked a single 12‑hour night shift and signed out multiple doses of controlled substances for six residents on narcotic control sheets without corresponding documentation of administration on the Medication Administration Records (MARs). For one resident with scheduled Oxycodone 10 mg three times daily and PRN Oxycodone 5 mg, Nurse #1 signed out Oxycodone 10 mg at times that did not match the scheduled administration times and documented one scheduled dose as given on the MAR, while also signing out PRN Oxycodone 5 mg on separate narcotic sheets that were not documented as administered on the MAR. A third narcotic sheet for this resident showed an unexplained change in tablet count from 28 to 26 without dates or signatures. For five additional residents with PRN orders for Hydromorphone, Oxycodone, Tramadol, and Hydrocodone‑Acetaminophen, Nurse #1 signed out multiple doses on the narcotic records during the same night shift, but none of these doses were documented as administered on the MARs by Nurse #1 or any other nurse. In two cases, narcotic sheets for Oxycodone 10 mg included entries where Nurse #1 documented wasting of tablets at illegible times, with Nurse #2 signing as a witness. However, the MARs for these residents contained no corresponding entries indicating that the medications had been administered. One nurse later reported that a resident whose PRN narcotics had been signed out denied taking the pain medication, and the MAR showed no administration entries for those doses. The facility became aware of the issue when a staff nurse (Nurse #3) noticed an unusual number of PRN narcotics signed out for a resident who typically did not request pain medication and found missing PRN Oxycodone that the resident denied receiving. Subsequent review of narcotic sign‑out sheets revealed discrepancies attributed to Nurse #1, including multiple narcotic withdrawals without MAR documentation for six residents. An email from the DON and Nurse #2 confirmed that Nurse #2 had signed as a waste witness for narcotics for two residents at Nurse #1’s request without actually observing the disposal. The pharmacist recalled the misappropriation of resident narcotics and confirmed that the facility later replaced all unaccounted‑for narcotic medications at facility expense.
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