Misappropriation of Discontinued Controlled Medications and Missing Narcotic Records
Penalty
Summary
Surveyors identified a deficiency related to misappropriation of resident property involving controlled medications for three residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. A second resident with dementia had an order for PRN oxycodone for moderate to severe pain, later discontinued, and was care planned as at risk for pain with interventions to administer pain medication as ordered. A third resident with dementia and anxiety had an order for PRN lorazepam for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that the second resident did not receive the ordered oxycodone. A facility reportable event documented that discontinued medications scheduled for destruction appeared to be missing, but initially did not identify which residents or which medications were involved. The incident was noted to have occurred in the afternoon, and the Medical Director and Consumer Protection were notified, but local law enforcement was not initially notified. Subsequent information identified that disposition sheets for controlled medications were missing and that the medications were last seen during a prior audit. The missing medications were quantified as 37 tablets of oxycodone 5 mg and 15 tablets of lorazepam 0.5 mg. Further facility documentation and interviews clarified that the missing controlled substances were discontinued medications belonging to the three residents: nine oxycodone tablets for the first resident, 28 oxycodone tablets for the second resident, and 15 lorazepam tablets for the third resident. The proof-of-use sheets and matching medication packs were missing from narcotic lock boxes on two different units, to which approximately 30 nurses had access during the period between two audits. The medications had been moved to the back of the narcotic lock boxes for later disposal, and the facility was unable to identify which nurse removed the medications or when they were removed. A memo from the Consumer Protection drug control division confirmed a significant loss of controlled substances, a procedural lapse in not segregating discontinued medications immediately, and the inability to reconcile inventory due to missing logs, while the medications were under the security of the narcotic lock boxes.
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