Failure to Report Alleged Misappropriation of Resident Narcotics
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Agency as required by regulation and facility policy. Specifically, concerns were raised regarding the administration of oxycodone to two cognitively intact residents with complex medical histories, including conditions such as cerebral infarction, congestive heart failure, multiple sclerosis, and various psychiatric and pain disorders. An LPN reported to nursing management that another nurse may have been forging signatures on narcotic logs related to the administration of oxycodone for these residents. This concern was based on observations and reports from other nurses, including suspicions of signature forgery. Despite these allegations, the Director of Nursing (DON) confirmed that an internal investigation was conducted, which included requiring all nurses in the affected area to undergo drug testing. However, the DON did not consider the situation to be an allegation of misappropriation and therefore did not report it to the State Agency, as required by both facility policy and state regulations. The facility's policy clearly states that all incidents and allegations of misappropriation must be reported immediately to the administrator or designee and to the state department of health within two hours if abuse or serious bodily injury is alleged. The failure to report the incident constituted non-compliance with regulatory requirements.