Failure to Report Drug Diversion and Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an alleged misappropriation of resident property involving a missing card of 59 oxycodone 10 mg tablets prescribed to a resident. The Director of Health Services (DHS) became aware of the missing medication and initiated an internal investigation by contacting the LPN who had last handled the medication. Initially, the LPN claimed to have destroyed the medication in the facility's medication room after the resident's death, but upon further questioning, admitted to taking the entire card of oxycodone tablets home. The LPN subsequently returned the full card of medication to the facility, and the pharmacist verified the tablets. Despite the clear evidence of potential drug diversion and misappropriation, the DHS did not report the incident to the State Survey Agency or adult protective services, as required by facility policy. The DHS stated that she did not consider the event to be an allegation of misappropriation and only followed the adverse incident reporting path. Facility policies reviewed indicated that such incidents should be reported to appropriate agencies within five working days, but this protocol was not followed in this case.