Failure to Report Suspected Drug Diversion to Regulatory Agencies
Penalty
Summary
The facility failed to report a suspected drug diversion involving narcotic medications for four residents to the appropriate regulatory agencies. Multiple discrepancies were identified in the administration and documentation of oxycodone and oxycodone-acetaminophen for residents with chronic pain and other serious conditions. For example, medication administration records and narcotic count sheets did not align, with doses being signed out at incorrect times, missing signatures, and mismatched tablet counts. In one case, a resident's narcotic card showed fewer tablets than should have remained, and in another, a medication card for comparison was not provided. Staff interviews revealed confusion and lack of clarity regarding medication administration and documentation. One LPN was observed to be impaired at work and was sent home, after which narcotic counts were found to be off. Staff reported these discrepancies to their supervisors, but a thorough reconciliation of medication records was not performed. The Corporate Nurse Consultant acknowledged that the narcotic counts were off but did not compare narcotic sheets with the Medication Administration Record during the investigation. Despite the facility's policy requiring immediate reporting of any suspected misappropriation of resident property, including drug diversion, to the State Regulatory Agency within 24 hours, the concerns were not reported as required. The investigation into the missing medications was incomplete, and the appropriate authorities were not notified of the suspected diversion, as mandated by facility policy and federal and state law.