Misappropriation and Diversion of Resident Narcotic Medications by Agency LPN
Penalty
Summary
The deficiency involves misappropriation of residents' narcotic medications by an agency LPN, resulting in missing oxycodone tablets and related narcotic documentation for four residents. One resident with quadriplegia, chronic pain syndrome, and anemia, who had intact cognition, had an order for oxycodone 10 mg every four hours as needed for pain; this resident was found to be missing an unknown amount of oxycodone tablets after the LPN forged other nursing staff signatures on the narcotic flow record. A second resident with malignant neoplasm of the left breast, morbid obesity, and generalized anxiety disorder, also cognitively intact, had an order for oxycodone 4 mg every four hours as needed for moderate to severe pain and was determined to be missing seven oxycodone tablets. A third resident, who had malignant neoplasm of the bronchus, bipolar disorder, and a brain disorder, with documented memory problems, had standing and as-needed oxycodone orders (5 mg four times daily and 10 mg every four hours as needed for increased pain) and was found to be missing 30 oxycodone tablets. A fourth resident with COPD, essential hypertension, and muscle wasting, cognitively intact and ordered oxycodone 5 mg one to two tablets every four hours as needed for pain, was missing an unknown amount of oxycodone because the LPN removed the remaining oxycodone card and narcotic flow record from the facility. The facility’s own investigation, as reflected in the misappropriation self-reported incident, substantiated that the agency LPN diverted narcotics from these four residents, contrary to the facility’s abuse prevention policy that requires protection from misappropriation of resident property.
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