Failure to Thoroughly Investigate Narcotic Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of narcotic medication misappropriation after multiple controlled medication discrepancies were identified involving a registered nurse. The facility's own documentation showed that controlled medications were signed out in the control log but not documented in the Medication Administration Record (MAR) for 17 residents. Despite this, only a portion of the affected residents were assessed for pain outcomes, and there was a lack of documented follow-up pain evaluations for 9 out of 14 residents listed in the facility's self-reported incident. Interviews with facility leadership revealed that the investigation into the medication discrepancies was incomplete, as not all affected residents were interviewed or had their pain outcomes evaluated and documented. The Director of Nursing stated that both verbal and written pain evaluations were conducted, but not all were documented. No evidence was provided to show that all residents potentially impacted by the medication discrepancies were properly assessed, resulting in an incomplete investigation of the alleged violation.