Failure to Thoroughly Investigate Missing Controlled Medication
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation involving missing controlled medication for a resident with end stage renal disease, anxiety, type 2 diabetes, and depression. The incident involved an incorrect count of Clonazepam, with 11 tablets missing, discovered during a routine medication count by two LVNs. Both nurses involved were interviewed, drug tested, and suspended pending investigation, but no other staff, residents, or responsible parties were interviewed at the time of the incident. Despite the resident having intact cognition, as indicated by a BIMS score of 15, neither the resident nor her responsible party was notified or interviewed regarding the missing medication. The facility's investigation did not include interviews with other residents who might have been involved or affected, nor did it verify with the resident whether any doses were missed or if there were any changes in her condition. The facility's own policy required interviewing all potential witnesses and identifying the alleged victim, but these steps were not followed during the initial investigation. Observations also revealed that medication counts were not being properly verified, with one staff member counting while the other only checked the sheet, rather than both verifying the physical count and the documentation. This practice was acknowledged by staff as a potential concern for medication security. The lack of a comprehensive investigation and failure to follow established procedures placed residents at risk of not having their allegations of abuse, neglect, or misappropriation thoroughly or timely investigated.