Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to thoroughly investigate an allegation of drug diversion involving a resident who reported that a nurse had exchanged their pain medication for a different pill on two occasions. The resident, who had intact memory and was familiar with their prescribed pain medication, documented their concerns in a grievance form, stating that they recognized the difference in the medication's appearance and suspected theft. The facility's investigation was limited to a review of the Medication Administration Record (MAR), narcotic sheet, and progress notes, which indicated the medication was administered and effective. However, the investigation did not include interviews with the resident regarding the effectiveness of the medication, did not identify or interview the nurse alleged to have diverted the medication, and did not include interviews with other residents or staff who may have been witnesses or involved. The investigation summary lacked essential details, such as the identity of the staff member who wrote it, and failed to follow the facility's policy, which required comprehensive interviews and documentation. Both the Director of Nursing and the Administrator acknowledged that the investigation did not meet policy requirements, as it did not determine which nurse was involved or whether the resident's concerns were fully addressed. The incident was not reported on the facility's state reporting log, and the process for determining whether the concern was a grievance or a reportable allegation was not clearly documented.