Failure to Safeguard Resident’s Controlled-Substance Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a controlled-substance pain medication was missing after delivery. The facility’s Abuse, Neglect, and Exploitation Policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. The resident involved was cognitively intact and had diagnoses including major depressive disorder, suicidal ideations, anxiety disorder, alcohol abuse with intoxication, insomnia, and muscle spasms of the back. The resident had an order for Norco (hydrocodone-acetaminophen) 10/325 mg, one tablet by mouth every eight hours as needed for pain. Pharmacy records and a proof of delivery/packing slip show that 30 tablets of this medication were delivered to the facility, and video evidence and a signed statement from an agency RN confirm that she received the delivery in the early morning, signed the pharmacy delivery sheets, and placed the 30 tablets in the medication cart. She also stated that when she left her shift, she counted all controlled medication cards and pills and found no discrepancies. The deficiency arose when the medication card for this resident’s Norco was later found to be missing. The DON learned that an LPN had attempted to reorder the Norco, but the pharmacy denied the request because the prescription had already been filled and sent. By the time the DON became aware that the Norco was missing, two days had passed since delivery. An audit of the controlled substance inventory sheets revealed that numerous nurses were not counting controlled substances and cards at the beginning and end of their shifts as required. Video surveillance could not confirm who took the medication because there were times when the medication cart was not visible. The DON reported that, after reviewing video footage, interviews, and medication records, she concluded that the only nurse who could have taken the Norco was a new agency RN, as all other nurses had worked there previously and there had been no prior issues with missing narcotics.
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