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F0609
E

Failure to Timely Report Suspected Medication Diversion

Polson, Montana Survey Completed on 11-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff members M and N failed to report a reasonable suspicion of a crime related to medication diversion in a timely manner to facility leadership. Staff member N had a conversation with staff member M at the beginning of August regarding suspicions about staff member L and signs of medication diversion, but neither reported these concerns to their supervisor or the administrator. Staff member M had ongoing suspicions over several months but did not communicate these to staff member N until early August. The issue came to light when a CNA reported to staff member A that M and N had suspicions of medication diversion. An investigation revealed that nine residents had medications diverted, but no other residents were found to be affected, and no other staff reported concerns. Both staff members M and N had completed abuse training, including the requirement to report reasonable suspicion of a crime, during their orientation. Their personnel files confirmed current nursing licenses and completed background checks. The facility's policy required immediate reporting of any reasonable suspicion of a crime to the Executive Director, but this was not followed by the involved staff members, resulting in a delay in addressing the medication diversion.

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