Failure to Investigate Misappropriation of Resident Medications
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident medications for five of eight residents. Multiple medication cards showed doses removed without proper documentation or explanation, and in several cases, medications were taken from one resident and given to another without following appropriate procedures. Staff interviews revealed that nurses were routinely directed by the Director of Nursing (DON) and other supervisory staff to borrow medications from one resident to administer to another when medications were unavailable, a practice that was reportedly common and sometimes accompanied by informal documentation on medication cards. Specific examples included medication cards for levothyroxine, potassium chloride, glipizide, clozapine, and oxycodone, where doses were removed and either not documented or documented as being given to other residents. In some cases, the initials on the medication cards could not be identified, and the dates and reasons for removal were unclear. Residents involved had a range of medical conditions, including hemiplegia, hypothyroidism, chronic kidney disease, schizoaffective disorder, and acute pain, and the medications in question were prescribed for these conditions. The practice of borrowing medications was confirmed by several nurses, who stated they received direct instructions from the DON or other supervisory staff to do so. Despite the discovery of these practices, the facility did not conduct a thorough investigation as required by its own policies. Interviews with human resources and administrative staff revealed confusion about who was responsible for the investigation, with some staff unaware of any completed investigation, education, corrective action, or audits. The facility's policy required a thorough investigation of misappropriation allegations, including identifying all involved parties, interviewing witnesses, and documenting findings, but these steps were not completed or documented as having been completed.