Failure to Timely Report Misappropriation of Resident Medications
Penalty
Summary
The facility failed to ensure that alleged violations involving the misappropriation of resident medications were reported to the state agency within 24 hours of the incidents, as required. The misappropriation involved at least five residents, where medications were removed from one resident's supply and administered to another without proper documentation or consent. Multiple medication cards showed doses removed and given to other residents, with some cards lacking clear documentation of the reason for removal, the date, or the initials of the staff involved. The practice of borrowing medications was confirmed through observation, record review, and staff interviews. Several staff members, including RNs, LPNs, and DONs, acknowledged that the practice of borrowing medications from one resident to give to another was common and often directed by nursing leadership. Staff interviews revealed that this practice occurred frequently, sometimes every other day, and that nurses were instructed to document the removal on the medication card, though this was inconsistently done. Residents and family members interviewed were unaware that medications had been borrowed from or for them, and there was uncertainty about whether any doses had been missed as a result. Despite knowledge of the misappropriation by various staff, including human resources and nursing leadership, the incidents were not reported to the state agency as required by facility policy and federal regulations. Staff cited reasons such as lack of access, uncertainty about reporting procedures, or not being involved in the investigation as reasons for not reporting. The facility's own policy defined misappropriation as the wrongful use of a resident's property without consent and required reporting within 24 hours, but this was not followed in these cases.