Misappropriation and Falsified Documentation of Controlled Medications by an LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled medications and to ensure accurate, non-fraudulent documentation of controlled drug administration. A concern was first raised when a nurse, during a change-of-shift controlled drug count, noticed that the count for a resident’s PRN medication had drastically changed since her prior shift, and that her own documentation had been altered. Subsequent review of controlled medication logbooks and MARs for multiple residents revealed overwritten entries, out-of-sequence entries, falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding MAR documentation. These irregularities involved six different controlled pain medications, including Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine, and affected ten residents across two units. Interviews and handwriting comparisons identified an LPN as the individual responsible for the irregular logbook entries. The Administrator confirmed that the LPN’s handwriting matched the questionable entries and that the LPN was involved in ten incidents of removing medications believed not to have been administered to the prescribed residents. The DON and other nursing staff reported that the controlled medication counts themselves were correct, but the signatures and dates in the logbooks did not match staff who had actually worked the shifts, and the sequence of dates was inconsistent with proper administration. The LPN was described as visibly shaky when asked to provide a handwriting sample and did not clearly deny involvement when questioned. It was also confirmed that this LPN did not hold an active state nursing license, and the facility acknowledged a failure to protect residents from this LPN’s misappropriation of medications.
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