Failure to Thoroughly Investigate Missing Medication Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident's property involving a resident with anxiety disorder and major depressive disorder, who had moderate cognitive impairment as indicated by a BIMS score of 11. The incident involved the disappearance of approximately six alprazolam tablets and the corresponding narcotic sheet from the medication cart, as reported by a CMA. The CMA searched for the missing narcotic sheet at the nurse's desk but was unable to locate it and subsequently reported the missing medication to the DON. Upon notification, the DON stated that an investigation was conducted; however, no written statements were obtained from staff members, and there were no notes documenting staff interviews. Additionally, the DON was unable to determine what happened to the missing medications. The lack of thorough documentation and follow-up in the investigation process led to the deficiency cited in the report.