Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication to the State Agency after a resident's family member reported missing oxycodone. The resident, who was cognitively intact and had multiple medical diagnoses including osteomyelitis, diabetes, and a tracheostomy, was admitted with an order for liquid oxycodone to be administered via G-tube. On the day the medication was brought in by the resident's daughter, staff did not verify the amount of oxycodone remaining in the bottle with the daughter, nor did they document the condition of the medication seal as required by facility policy. The Narcotic Administration Sheet indicated the medication was signed in, but there was no documentation of the seal's condition or any doses administered. Subsequently, concerns were raised by nursing staff about the appearance and integrity of the medication, and the resident's daughter reported the medication as stolen to the police. Despite this allegation and the involvement of law enforcement, the facility did not report the incident to the State Agency, as the DON believed the medication was accounted for. Review of facility records and the ODH Gateway Application confirmed that no self-reported incident was filed regarding this allegation of misappropriation.