Misappropriation of Resident’s Controlled Lorazepam and Resulting Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a controlled medication, Lorazepam 0.5 mg, went missing from the medication cart, resulting in missed doses. During a narcotic count at shift change on 11/30/25, RN A and the night shift nurse (RN B) were unable to locate the resident’s Lorazepam bubble pack, which should have contained 19 tablets according to the narcotic record. RN A reported that three medication carts and 48 resident rooms were checked, but the medication could not be found, and confirmed that the resident missed two scheduled doses on 11/30/25 and 12/1/25. The facility’s controlled substances policy required controlled medications to be reconciled upon receipt, administration, disposition, and at the end of each shift, with incoming and outgoing nurses jointly determining the count. Interviews and record review established that the Lorazepam had been present and accounted for at the end of the prior shift. RN B stated that at the start of her night shift on 11/29/25 all narcotics were accounted for, and at the end of her shift RN A discovered the Lorazepam bubble pack was missing, despite the narcotic record book indicating 19 tablets remained. RN C, who worked the evening shift before RN B, confirmed that all narcotics, including the resident’s Lorazepam, were accounted for during the count with RN B, and both signed the narcotic book indicating no discrepancies. The MDS Coordinator later found a torn medication label from the missing Lorazepam bubble pack in the bottom drawer of a bedside table in an empty room, but the 19 tablets were not recovered. The DON confirmed that the medication had been accounted for on 11/29/25, was missing during RN B’s night shift, and that the torn label matched the missing Lorazepam, constituting misappropriation of the resident’s property in violation of the facility’s resident rights and misappropriation policies.
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