Failure to Prevent Neglect and Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect and misappropriation of property, as evidenced by two main deficiencies. One resident, who was care planned for overactive bladder and required a two-person assist for transfers and toileting, reported that he called for help throughout the night but did not receive assistance. Multiple staff interviews and the facility's own investigation confirmed that the resident was found in the morning with a full urinal, wet bed, and wet brief, and that there was no documentation of care provided or refusals during the night shift. Staff acknowledged that it was not uncommon to find residents wet and call lights on at shift change, and the Director of Nursing confirmed a lack of documentation for care provided on multiple shifts. Additionally, the facility failed to have effective processes in place to prevent the misappropriation of controlled substances for two residents. Pharmacy records and controlled substance logs revealed that one resident received more doses of a controlled medication than prescribed, with documentation showing up to 11 doses in a single day when only four were ordered. The logs were found to be illegible, with dates scribbled over and not in order, and similar discrepancies were found for another resident's controlled medication. The pharmacy consultant and facility staff confirmed that the counts were correct, but the administration records were inaccurate and not properly reconciled. Interviews with staff, including the DON, Risk Manager, and LPNs, revealed that one LPN was associated with multiple documentation discrepancies, including altered dates and signatures she could not recall. The facility's investigation verified these issues, and the LPN denied taking any pills or overmedicating residents. The lack of accurate documentation and oversight led to the inability to ensure that residents received medications as ordered and that their property was safeguarded.