Unresolved Misappropriation of a Resident’s Oxycodone Medication Card
Penalty
Summary
The facility failed to protect a resident’s belongings by not preventing the misappropriation of a narcotic medication, Oxycodone, prescribed for chronic pain. The cognitively intact resident had physician orders for Oxycodone 5 mg tablets, with directions to take 10 mg for moderate pain and 15 mg for severe pain as needed. Pharmacy records showed that three blister cards, each containing 30 tablets of Oxycodone 5 mg, were delivered and signed in by two nurses. At the time of the incident, the resident had additional Oxycodone cards available and had not missed any doses. On one evening shift, a medication aide working the day shift completed a controlled substance count with an RN at shift change, and they documented a total of 27 narcotic medication cards for residents on that hall, including the resident’s Oxycodone. The medication aide reported that the count was correct at that time and that she had not previously noticed missing narcotics on that cart. Later, during the next shift change between the night nurse and the oncoming nurse, the two nurses again counted the controlled medications and discovered that one Oxycodone card for the resident, containing 30 tablets, was missing. They noted that there were 27 controlled substance record sheets but only 26 corresponding medication cards. The unit manager verified the discrepancy by recounting the medications on the cart and confirmed that one Oxycodone card was missing when compared to the controlled substance count sheets. A 100% audit of all medication carts and medication storage rooms was conducted by the unit manager and the prior DON, and the missing Oxycodone card could not be located. The facility’s pharmacist later confirmed that no Oxycodone 5 mg for this resident had been returned to the pharmacy around the time of the loss. Interviews with staff and the resident confirmed that the resident continued to receive pain medication as needed, but the facility was unable to determine how the narcotic card was lost, resulting in an unresolved misappropriation of the resident’s medication.
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