Failure to Timely Report Missing Narcotics to State Agency
Penalty
Summary
The facility failed to report a potential misappropriation of a resident's property, specifically missing narcotics, to the State Agency (SA) within the required 24-hour timeframe after the allegation was made. A resident with diagnoses including dementia, bipolar disorder, and chronic kidney disease was prescribed morphine sulfate and lorazepam as part of hospice care. On the evening of 4/11/25, a nurse identified a discrepancy in the narcotic count for this resident and notified the registered nurse (RN)-B via email. RN-B responded to the email but did not initiate further action until the following day and did not inform the facility administrator until the afternoon of 4/14/25, stating she did not initially consider it a concern. The administrator confirmed that she was not made aware of the missing narcotics until 4/14/25 and did not report the incident to the SA at that time, as the investigation was still ongoing and not completed until 4/18/25. Interviews with other nursing staff indicated an understanding that missing medications should be reported to administration immediately and to the SA within 24 hours. The facility's policy also required all alleged violations of misappropriation to be reported to the administrator and appropriate authorities within 24 hours. The delay in reporting the missing narcotics constituted a failure to follow both regulatory requirements and facility policy.