Failure to Timely Report Alleged Abuse and Drug Diversion Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime, abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but no later than 2 hours after the suspicion or allegation was made, to a law enforcement entity or State Agency in accordance with State law. This deficiency was identified in the case of a male resident with a history of drug and alcohol abuse, congestive heart failure, stroke, and major depressive disorder. The resident was found unresponsive in his room, required emergency intervention with Narcan, and was subsequently hospitalized, where he tested positive for Methadone, a medication for which he did not have a physician's order. Upon return to the facility, the resident alleged that he had received Methadone from a staff member, though he refused to identify the individual. Facility records and interviews confirmed that the resident had not signed out of the facility, and there was no evidence of an order for Methadone in his medical records. Staff interviews indicated that the resident was found in respiratory distress and that the cause of his condition was initially unclear, but later suspected to be a drug overdose based on hospital records. Despite the resident's allegation and the positive drug test, the facility did not immediately report the incident to law enforcement or the State Agency as required by policy and regulation. The Director of Nursing (DON) and Administrator were aware of the hospital findings and the resident's statements but delayed reporting the incident while they gathered more information. The facility's policies required immediate reporting of suspected abuse or criminal acts, but the only actions taken prior to the surveyor's intervention were staff in-services, a care plan meeting, and scheduling a Resident Council meeting. There was no evidence of timely notification to authorities, medication audits, or a formal investigation initiated within the required timeframe.