Failure to Report Misappropriation of Narcotic Medications to State Agency
Penalty
Summary
The facility failed to report an allegation of misappropriation of narcotic contingency medications to the State Agency (SA) after discovering missing doses of controlled substances. On 1/11/25, staff identified that several narcotic medications, including fentanyl patches, morphine tablets, oxycodone, Oxycontin, and hydrocodone/APAP, were missing from the contingency box. The incident was reported to local law enforcement, but there was no documentation or evidence that the potential misappropriation was reported to the SA as required by facility policy and regulatory expectations. Interviews with nursing staff revealed that the process for accessing and checking the narcotic contingency box was changed following the incident, with new procedures for verifying tag numbers and conducting visual inspections at shift changes. However, the investigation documentation and administrator interview confirmed that the SA was not notified of the missing medications. The failure to report the suspected misappropriation had the potential to affect any residents who might have needed the diverted medications.