Misappropriation of Narcotics Misreported
Penalty
Summary
The facility failed to accurately report an incident involving the misappropriation of narcotics, specifically morphine 20MG/ML bottles, for two residents. During a clinical record review and staff interviews, it was discovered that the morphine bottles for these residents had been tampered with. The facility had entered this incident into the state reporting system under the incorrect category of "other" instead of "misappropriation of patient/resident property." Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the misclassification of the incident. This misreporting was identified during a review of four facility-reported incidents, highlighting a deficiency in the facility's reporting practices. The failure to accurately categorize the incident in the state reporting system indicates a lapse in the facility's management and responsibility to ensure proper documentation and reporting of significant events.
Plan Of Correction
A - Resident's morphine was replaced at the cost of the facility and not charged to resident's insurance. B - Audit of all reportable incidents in last 30 days to ensure reported accurately. C - Previous DON and NHA educated on proper classification of reportable incidents of misappropriation in the PA event reporting system. Current DON and NHA aware of reporting category. D - Weekly x 4 then monthly x 2 audits by regional nurse or designee of reportable incidents to ensure accurate reporting. Results discussed during QAPI meetings.