Misappropriation of Discontinued Resident Medications and Inadequate Medication Control
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their medications, which are considered the residents’ belongings. Ten residents had medications that were later found in the home of a former LPN who had worked part‑time at the facility. These residents had various diagnoses including paranoid schizophrenia, Alzheimer’s disease, bipolar and schizoaffective disorders, COPD, diabetes, osteoarthritis, paraplegia, end‑stage renal disease, and anxiety disorders. Their treatment regimens included antipsychotics, antidepressants, antianxiety agents, anticonvulsants, opioids, antibiotics, antiplatelet agents, hypoglycemics, and other medications such as ibuprofen, quetiapine, ondansetron, hydroxyzine, olanzapine, cyproheptadine, ampicillin, gabapentin, metronidazole, and baclofen. The Ohio Board of Pharmacy and law enforcement identified probable drug diversion by an LPN who had worked at the facility. After the LPN’s death from an overdose of prescription drugs, medications labeled for ten different residents from the facility were found at the LPN’s residence. These included ibuprofen 600 mg and 800 mg, quetiapine 100 mg, ondansetron 4 mg, hydroxyzine 25 mg, olanzapine 10 mg, cyproheptadine 4 mg, ampicillin 500 mg, metronidazole 500 mg, baclofen 10 mg, and an empty blister pack of gabapentin 300 mg. The medications had been discontinued at the facility, and the Board of Pharmacy determined they had been removed from the facility after discontinuation and after residents were discharged or transferred. During the Board of Pharmacy’s inspection of the facility, multiple documentation and control issues were identified that related to the handling and security of medications. Signatures on controlled drug documentation were inconsistent, with variations in initials and full names, and some shift‑to‑shift narcotic counts were pre‑signed by the off‑going nurse. Documentation on medication cards or sheets did not always match the actual count, and some shift‑to‑shift counts were missing dates, signatures, and counts. Facility staff, including the Regional Director of Clinical Operations and an LPN, explained that when non‑narcotic medications were discontinued, nurses were expected to remove them from the medication cart and place them in a pharmacy return bag, but there was no method to verify that this actually occurred. The facility’s own abuse, neglect, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the findings showed that discontinued resident medications were not adequately secured or tracked, allowing them to be wrongfully removed and found in the former employee’s home.
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