Failure to Complete and Submit Timely Investigation of Misappropriation Allegations
Penalty
Summary
The facility failed to ensure that all allegations of resident abuse and misappropriation were thoroughly investigated and that complete investigation results were submitted to the State Survey Agency within five working days, as required by policy. Specifically, an incident was reported in which a resident was discharged home with a prescription for Oxycodone, but upon arrival, the responsible party discovered that 11 tablets were missing. The responsible party contacted the facility and spoke with an LPN who had been assigned to the resident on the day of discharge. The LPN stated she had the remaining pills in a prescription bottle, which was not the facility's standard practice, as medications are typically dispensed on a unit-dose card. An internal review also revealed that another resident, recently discharged to the hospital, was missing 32 Hydrocodone tablets, and the required controlled substance sign-out sheets for both residents' medications were missing. Although the facility initiated an investigation and submitted a report through the Electronic Reporting System, the report was incomplete and lacked required supporting documentation such as witness statements and confirmation that all necessary components were included. The incomplete report was rejected by the State Survey Agency, and the facility did not submit a revised, complete investigation for review. During interviews, facility leadership was unable to provide documented evidence that the investigation was completed in full and submitted within the required timeframe.