Failure to Report Missing Controlled Substance
Penalty
Summary
The facility failed to identify and report the diversion of a resident's controlled substance, specifically lorazepam. According to the medication administration record and controlled drug count sheet, a discrepancy of 4.0 ml of lorazepam was noted during a routine count, with two nurses signing off on the correction. Despite this discrepancy, there was no documentation or evidence that the missing medication was reported to facility administration or to the appropriate authorities. Interviews with nursing staff revealed that one nurse believed the other would report the issue, but neither confirmed that a report was made. The Assistant Director of Nursing confirmed that the missing lorazepam had not been reported, and the new Administrator, who also serves as the abuse coordinator, stated she was not made aware of the incident. The facility's policy requires prompt reporting of any suspected abuse, neglect, or misappropriation of resident property, including controlled substance discrepancies, to local, state, and federal agencies. The failure to report the missing lorazepam as required by policy and regulation resulted in a deficiency related to the timely reporting of suspected theft or diversion of a resident's medication.