Misappropriation of Discontinued Resident Medication by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when an RN removed discontinued prescription medication belonging to the resident from the facility. The resident was an older individual with senile degeneration of the brain, difficulty walking, and a cognitive communication deficit, and had a BIMS score of 03 indicating severe cognitive impairment. The resident had previously been ordered Meloxicam 7.5 mg, an NSAID for pain and inflammation, with the order ending in late October. Medication Administration Records showed the resident had not received Meloxicam since late October, and there were no current orders for the drug at the time of the incident. During medication cart activities, a medication aide identified two full blister cards (60 tablets total) of Meloxicam for this resident on the cart and brought them to the RN, asking if the medication was still needed. The RN verified in the electronic medical record that the medication had been discontinued. According to the medication aide, she normally would have placed discontinued medications in a locked discontinued box in the medication room after verification, but on this occasion the RN stated she would handle it. The aide reported that the RN placed the two full cards near her computer, and the aide did not see what happened to them afterward. Subsequently, during a police traffic stop unrelated to the facility, law enforcement found two full blister cards containing 60 tablets of Meloxicam 7.5 mg in the RN’s car. A police report identified the pills as belonging to the resident and classified the incident type as criminal. The RN did not deny having the medication and later emailed the facility’s executive director, stating that during a very busy shift she had placed blister-pack medications under papers at the nurse’s station and inadvertently gathered them with her personal belongings when leaving. The executive director, however, stated that the RN had the two full cards in a small laptop case and expressed the belief that the RN could not have taken them accidentally. Facility leadership and the director of clinical operations confirmed that the medication belonged to the resident, that it was discontinued, and that the RN had taken it from the facility, constituting misappropriation of resident property. The facility’s abuse policy stated that each resident has the right to be free from misappropriation of property and that staff must adhere to policies and procedures to prevent such incidents. The storage of medications policy required that all drugs be stored in a safe, secure, and orderly manner and that discontinued drugs be returned to the pharmacy or destroyed. In this case, the RN did not immediately secure the discontinued medication in the locked discontinued box as expected, and instead the resident’s medication was found off-site in the RN’s possession, leading to the determination that the resident was not kept free from misappropriation of property.
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