Failure to Properly Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to fully investigate allegations of misappropriation involving two residents who were both cognitively intact and had physician orders for oxycodone for pain management. For one resident, the medical record showed an admission with multiple complex diagnoses, including dementia, heart failure, and chronic pain, while the other had a history of conditions such as antiphospholipid syndrome, depression, and fibromyalgia. Both residents had ongoing orders for oxycodone, and their Minimum Data Set assessments confirmed cognitive intactness at the time of the events. The Director of Nursing (DON) confirmed that an investigation was conducted regarding a nurse and the administration of narcotics, but no written statements were obtained from staff or residents. The DON stated that only face-to-face interviews were conducted with the nurses involved, and no documentation of interviews or statements from any potential resident victims was completed. This approach was not in accordance with the facility's policy, which requires interviews with the resident, the accused, and all witnesses, as well as documentation of the investigation. The lack of proper documentation and failure to interview residents directly led to the deficiency.