Failure to Report Suspected Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident medication to the State Survey Agency as required by regulation. Documentation and staff interviews revealed that an LPN was observed by another LPN removing two Xanax tablets from a resident's medication card, despite the medication being ordered as PRN and only one tablet being indicated. The witness also noted discrepancies in the narcotic log, with several medications being administered twice in a short time frame. The incident was immediately reported to the ADON and Staff Educator, and further review of the medication administration records and narcotic logs indicated probable diversion of medications. Following the internal investigation, the NHA and DON were notified, and the police were called to the facility. The LPN in question was found to be impaired and refused a urine test, after which they were escorted from the facility by police. Despite these findings and actions, the NHA confirmed that the incident was not reported to the State Survey Agency, citing direction from the corporate office. This omission constitutes a failure to comply with mandatory reporting requirements for suspected misappropriation.