Unexplained Loss of Controlled Anxiolytic Medication for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property by not ensuring appropriate controls and interventions were in place to prevent the misappropriation of a controlled medication. The facility’s Abuse and Retaliation Policy Prevention Program affirms residents’ rights to be free from misappropriation of property. A Proof of Delivery form dated 2/7/26 shows that a 30 ml bottle of Lorazepam 2 mg/ml was delivered and signed in by a registered nurse (V4). The resident (R1) had an order for Lorazepam oral concentrate 0.25 ml by mouth every two hours as needed for anxiety for 14 days. The Controlled Drug Receipt/Record/Disposition form for R1, also dated 2/7/26, documents that the 30 ml vial was received and that only two doses of 0.25 ml each were signed out on 2/12/26 at 5:19 p.m. and 10:15 p.m., which should have left nearly the entire bottle remaining. On 2/13/26, the DON (V2) was notified by the ADON (V3) of an incorrect narcotic count for R1’s Lorazepam. V2 compared the remaining amount of medication in the bottle with the count sheet and confirmed the count was inaccurate. V2’s review did not identify any undocumented administered doses. V3 reported receiving a call from a registered nurse (V6) stating that R1’s Lorazepam was missing and that there was less than 1 ml in the bottle that was supposed to be full; V6 also sent V3 a picture showing less than 1 ml of liquid in the bottle. V6 stated she discovered the discrepancy when she went to administer a 0.25 ml dose and observed that there was less than 1 ml left, and verified that she had not given or spilled any of the medication and that it was gone before she attempted to administer it. Despite interviews with all staff who had access to the medication, everyone denied giving, spilling, or accessing the bottle, and the facility could not determine what happened to the resident’s Lorazepam.
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