Misappropriation of Resident Narcotic Medication Due to Inadequate Control of Pharmacy Deliveries
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically a controlled pain medication, from misappropriation. A cognitively severely impaired resident with colon cancer was admitted with an order for Hydrocodone-Acetaminophen 10-325 mg, one tablet three times daily. During a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic medication was missing and contacted the pharmacy to obtain a refill. The pharmacy reported that the facility should already have 120 tablets of the medication on hand, prompting a review of medication records and counts. Review of proof-of-use sheets and shift narcotic counts showed that the 120 tablets of Hydrocodone-Acetaminophen had not been administered, destroyed, or documented as wasted and were unaccounted for. Chain-of-custody review identified a nurse as potentially involved in the missing medication, and this nurse was no longer employed at the facility as of several days prior to the discovery. Interviews with nursing staff indicated that the medication was likely taken by a staff member when the pharmacy shipment was delivered, and that the nurse in question had not been signing for the pharmacy medication box upon delivery. Further interviews revealed that the pharmacy medication boxes arrived as regular cardboard packages taped with packaging tape, without locks or tamper-proof features, and were sometimes left in the front office among other delivered packages. Staff reported that it would have been easy for anyone, including staff or delivery personnel, to open and retape the boxes, and that in this case the entire inventory list, four narcotic count sheets totaling 120 pills, and four packages of 30 pills each were missing from the box. The facility’s Abuse, Neglect and Exploitation policy stated that the facility would prohibit and prevent misappropriation of resident property, but the policy did not address or reference the State Operations Manual or protocol specific to misappropriation (F602).
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