Failure to Report Missing Narcotic Medications as Required by Facility Policy
Penalty
Summary
The facility failed to follow its own policy and procedure regarding Unusual Occurrence Reporting when missing narcotic controlled medications were not reported to the California Department of Public Health (CDPH). On 6/18/25, it was discovered that four oxycodone, four Percocet, and four Norco tablets were missing from the emergency kit (E-kit), which contains a pre-determined supply of medications, including controlled substances, for immediate patient needs. Despite this discovery, the incident was not reported to CDPH as required by the facility's policy. During interviews and record reviews, the Director of Nursing (DON) confirmed the discovery of the missing narcotics, and the Administrator acknowledged that the facility had not reported the incident, even though the policy clearly states that such occurrences must be reported to the appropriate state or federal agencies within 24 hours by telephone and then confirmed in writing. The policy also specifies that allegations of misappropriation of resident property and other occurrences affecting the welfare, safety, or health of residents, employees, or visitors must be reported. The failure to report the missing narcotics was a direct violation of the facility's established procedures.