Failure to Timely Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to timely report a suspicion of misappropriation of narcotics involving a resident with multiple chronic conditions, including multiple sclerosis, hypertension, major depressive disorder, diabetes mellitus, conversion disorder with seizures, and chronic kidney disease. The resident was cognitively intact at the time of the incident. The Director of Nursing (DON) discovered several blank entries with the same handwriting in the narcotic book, indicating a registered nurse's signature, and found discrepancies between the Controlled Drug Records and the Medication Administration Records (MAR) for both Tramadol and Ativan. The resident reported not knowing about or requesting pain medication. Despite these findings, the DON concluded there was not enough evidence to confirm misappropriation but noted a concerning pattern of documentation errors. The DON immediately reported the suspicion to the Administrator, who, along with the President of Operations, advised the suspension of the nurse involved. However, the Administrator did not timely file a Self-Reported Incident (SRI) with the Ohio Department of Health as required by facility policy, which mandates notification of all alleged violations involving misappropriation within 24 hours. The investigation did not yield sufficient evidence to prove misappropriation, but the failure to report the suspicion in a timely manner constituted the deficiency.