Failure to Thoroughly Investigate Missing Controlled Substances
Penalty
Summary
The facility failed to thoroughly investigate the disappearance of controlled substances prescribed to Resident #76, who had diagnoses including malignant neoplasm of the anus, depression, neoplasm-related pain, insomnia, and osteoarthritis. The resident was cognitively intact at the time of the incident. On the date in question, a nurse discovered that the resident's narcotics were missing when attempting to dispense them. Documentation showed that an agency nurse had signed for the delivery of the medications, but the narcotics were not available for administration. The facility's investigation included reviewing proof of delivery, interviewing and drug testing three nurses, and reviewing medication administration records. However, only two staff members provided witness statements, and only three nurses were drug tested, despite more staff being present during the shift. The Director of Nursing (DON) confirmed that only the three involved nurses were interviewed and did not believe nurse aides would have relevant information, so they were not interviewed. The DON also stated that an assessment of the resident was performed, but there was no documentation to support this. The facility's Abuse Prohibition Policy requires thorough investigation and documentation of all allegations of misappropriation, including assessment and documentation in the medical record, but these steps were not fully completed. The investigation was ultimately inconclusive, and not all potential witnesses or involved staff were interviewed or tested as part of the process.