Failure to Report and Investigate Alleged Medication Tampering and Staff Impairment
Penalty
Summary
The facility failed to implement its policy for reporting and investigating allegations of abuse, neglect, and misappropriation of property when concerns were raised about possible tampering with a resident's liquid morphine and the apparent impairment of a nurse. Two nurses observed that the morphine appeared diluted and a different color, and that a new bottle's seal appeared tampered with. These concerns were reported to the Unit Manager, Assistant Director of Nursing (ADON), and Director of Nursing (DON), but the allegations were not reported to the State Agency, law enforcement, or Adult Protective Services as required by facility policy and regulations. Additionally, a thorough investigation was not conducted, and the accused nurse was not suspended or drug tested despite multiple staff observations of impairment. The resident involved had a history of prostate cancer, was on comfort measures, and was receiving scheduled opioid medication for pain and air hunger. The medication administration records and narcotic count sheets did not show discrepancies, and the resident did not display signs of pain or distress during the period in question. However, staff noted that the morphine's appearance was unusual and that the seal on a new bottle was not intact. The pharmacy was contacted but could not dispense a new bottle without a new prescription, which was subsequently obtained from the Medical Director. Despite written statements from staff and direct reports to nursing leadership, the DON did not initiate a formal investigation or report the incident to the required authorities. The DON expressed uncertainty about the policy regarding drug testing staff and did not follow up with the accused nurse, who resigned shortly after the incident. The Administrator later acknowledged that the appropriate steps to investigate and report the allegation were not completed because the facility believed the medication was accounted for.