Failure to Protect Resident’s Personal Narcotic Medication From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s belongings, specifically prescription pain medication, from misappropriation. A cognitively intact resident with a left tibia/fibula fracture was admitted with personal belongings, and later reported that four hydrocodone/acetaminophen tablets she had brought in her purse from home were missing when she wanted to take one for increased pain. The resident’s admission inventory sheet did not list any medications, and the facility’s own summary documented that the resident told the administrator she had a bottle in her purse with four hydrocodone tablets that were now gone, stating that a “skinny little nurse probably took them last night.” The facility’s abuse, neglect, and exploitation policy required protections against misappropriation of resident property, but the DON stated she was unsure whether nurses asked about medications during admission, indicating that medications brought from home were not consistently inventoried. Multiple staff interviews described a nurse (RN AA) working on the same unit who appeared to be under the influence while on duty, raising concerns about medication handling and resident safety. Staff reported that this nurse was not passing medications as expected, was weaving and wobbling, had uncontrolled facial movements, was found asleep at the medication cart, and required other staff to notify the NHA and remove her medication cart keys. CNAs and another nurse stated that residents commented the nurse was “cooked” and “wiped out,” and one staff member reported that another resident received the wrong medications. A confidential resident also described the nurse as being “higher than a [NAME]” and “F**ked up,” hiding in an alcove. The NHA confirmed that the nurse was behaving out of the ordinary and was terminated after refusing a drug test. The facility’s internal summary of the missing narcotic documented that the resident’s admission inventory did not reflect any medications from home, despite the resident’s report that she had brought hydrocodone in her purse. When the administrator later examined the purse, an empty hydrocodone bottle and other medications (gabapentin and ondansetron) were found and counted, and a subsequent room search with the resident’s permission revealed marijuana gummies, cigarettes, and a lighter. These findings, combined with the lack of documented medication inventory at admission and the presence of a nurse suspected by multiple staff and a resident of being under the influence while having access to medications, demonstrate the facility’s failure to protect the resident’s property from potential misappropriation as required by its abuse, neglect, and exploitation policy.
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