Failure to Document Investigation of Narcotic Discrepancy
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible misappropriation of a resident's narcotic medication was thoroughly investigated. A discrepancy was identified in the appearance of a resident's liquid Morphine, which appeared lighter in color than usual. The facility reported the incident to the State Agency, notified the police, removed the medication from the cart, and conducted interviews and pain assessments. The facility's investigation concluded that there was no substantiated evidence of misuse and suggested the color change could be due to the medication's age and infrequent use. However, the facility committed to conducting weekly audits of narcotic medication counts for six weeks to enhance monitoring, including documentation of the color and consistency of all liquid medications. When the surveyor requested documentation of these audits, the facility was unable to provide them. Despite multiple requests and attempts to locate the records, the facility could not produce evidence that the weekly audits were performed, leaving it unclear whether a thorough investigation into the potential misappropriation was completed.