Misappropriation of Controlled Medication Through Drug Diversion
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from misappropriation of property, specifically controlled medication (liquid Morphine). The resident, who had advanced dementia and was enrolled in hospice, had physician orders for Morphine concentrate 20 mg/mL, initially at 0.5 mL by mouth every hour as needed for shortness of breath or pain, later changed to 0.25 mL every 4 hours as needed after the physician observed the resident was very drowsy. The March Medication Administration Record (MAR) showed multiple administrations of 0.5 mL Morphine on various dates by two nurses, and later 0.25 mL doses primarily by one nurse. The controlled substance count record indicated the pharmacy supplied a 30 mL Morphine solution, and on one date a nurse documented withdrawing 0.25 mL with 13.5 mL remaining in the bottle. Review of hospice notes from mid-March to early April documented that the resident was not in distress and did not report pain, and there were no nursing notes during that period indicating the resident was in pain or discomfort. Despite this, the MAR reflected frequent PRN Morphine administrations, particularly by one nurse, and an unusually high administration frequency compared to other nurses. An audit of the controlled substance records identified discrepancies between the doses logged out and the doses documented as administered to the resident, resulting in a determination that 3.75 mL of Morphine was missing. The facility’s investigation substantiated drug diversion and identified one nurse as responsible based on the pattern of administration and documentation discrepancies. The facility became aware of a discrepancy involving the resident’s liquid Morphine when a nurse noticed an issue with the controlled substance count sheet and reported it as a possible mathematical error at the end of her shift. The DON initially believed the discrepancy was due to incorrect math but, upon further review of the documentation and signatures on the controlled substance count sheets, recognized an actual discrepancy in addition to calculation errors. The DON noted that one nurse had frequently administered the Morphine and was the last to administer it, while another nurse had possession of the keys when the discrepancy was first noticed but did not report it immediately. The Administrator and Medical Director were informed of the missing Morphine and the suspected drug diversion, and the Medical Director assessed the resident and found no documented negative outcomes, but the core deficiency remained the misappropriation of the resident’s controlled medication as evidenced by the missing 3.75 mL of Morphine and the documented discrepancies.
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