Failure to Investigate Alleged Narcotic Diversion
Penalty
Summary
The facility failed to implement its abuse prohibition policy in response to an allegation of misappropriation of a resident's property, specifically regarding the potential diversion of narcotic medications. A resident with dementia, bipolar disorder, and chronic kidney disease, who was receiving hospice care and prescribed liquid morphine and lorazepam, was found to have discrepancies in the counts of these medications. An LPN reported the morphine count was significantly off at the end of her shift and later noted a similar issue with lorazepam. Despite these reports, the nurse manager did not conduct a facility-wide narcotic count or initiate an investigation, instead attributing the discrepancies to possible spillage or evaporation after speaking with another nurse. The administrator was not informed of the issue until several days later and also did not initiate an investigation at that time, again attributing the discrepancies to spillage or evaporation. An investigation into the missing narcotics was only started after the administrator received an anonymous note several days after the initial report, which specifically alleged narcotic diversion and referenced inaccurate counts at the time of medication destruction. The facility was unable to provide documentation of an investigation into the incident, and the only evidence of follow-up was documentation of nurse training on narcotic counts, which did not include guidance on reconciling discrepancies. The facility's own policy required a thorough investigation into allegations of misappropriation, including interviews, documentation review, and a root-cause analysis, none of which were completed in this case.