Failure to Timely Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of narcotic medications to the appropriate state agency, as required by policy. For one resident with a history of liver disease and moderate cognitive impairment, records showed a narcotic was signed out as administered by an LPN, but there was no corresponding documentation in the Medication Administration Record (MAR) or progress notes to confirm the medication was given. Similarly, for another resident with severe cognitive impairment and chronic pain conditions, a narcotic was signed out as administered, but again, there was no documentation in the MAR or progress notes to support that the medication was actually given. A facility investigation into narcotic diversion revealed that the LPN in question tested positive for multiple narcotics and was subsequently suspended and reported to the Board of Nursing. Despite these findings and the facility's own policy requiring immediate reporting of such allegations to the state health department, no self-reported incident (SRI) was filed with the Ohio Department of Health regarding the suspected misappropriation of narcotics. Interviews with the Administrator and Director of Nursing confirmed that they were aware of the suspicions and investigation but did not report the incident to the state agency, as they believed they could not prove misappropriation since residents did receive pain medications. The facility's policy clearly defined misappropriation and required reporting within 24 hours of an allegation, but this protocol was not followed in these cases.