Failure to Protect Resident Medication from Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s personal property, specifically a prescribed medication, and ensure it was available for use. The resident was admitted with diabetes and had an active order for weekly Ozempic injections for DM2. According to the facility’s abuse policy, misappropriation of resident property includes intentional theft or mishandling of a resident’s money or property by personnel authorized to handle it. The resident’s quarterly MDS showed normal cognition, and there is no indication that the resident gave anyone permission to take any of their medications. On the morning of 6/8/25, an LPN signed for delivery of three Ozempic pens for the resident and placed them in the refrigerator in the locked medication room on the third floor. On the morning of 6/13/25, another LPN was unable to locate the Ozempic in that refrigerator. The medication, which had been properly delivered and stored in a secure area accessible only to nurses, was missing when needed for administration. As a result, the facility did not have the resident’s ordered Ozempic dose available at the scheduled time, constituting a failure to protect the resident’s property and ensure its availability for the resident’s use.
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