Failure to Timely Report Medication Misappropriation Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of medications to the Department of Health and Senior Services (DHSS) and law enforcement within the required twenty-four hour timeframe. Staff discovered missing narcotic medications for three residents and reported the issue to the Administrator. The facility's policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation to the appropriate agencies, including the state agency, within prescribed timeframes. Despite this, documentation showed that the facility did not notify DHSS regarding the misappropriation allegation. The investigation revealed that a possible diversion of medications was identified when staff noticed unaccounted-for narcotic medications and discrepancies in the medication dispensing records. Specifically, more hydrocodone/acetaminophen tablets were dispensed than ordered, and destruction logs provided by the implicated nurse appeared altered. The nurse in question was suspended pending investigation, but there was no evidence that the incident was reported to DHSS as required by policy and regulation. Interviews with various staff members, including LPNs, CNAs, and CMTs, indicated that they understood the requirement to report allegations of misappropriation to the Administrator and that the Administrator was responsible for reporting to DHSS within two hours. However, the former Administrator stated that after consulting with regional leadership, it was decided not to report the incident to DHSS, resulting in a failure to comply with mandatory reporting requirements.