Failure to Timely Report and Investigate Missing Narcotics
Penalty
Summary
The facility failed to report an allegation of missing narcotics involving two residents, both of whom had controlled substances prescribed and delivered, but discrepancies were found in the medication counts and documentation. One resident, with diagnoses including chronic kidney disease, diabetes, congestive heart failure, and bipolar disorder, was prescribed Oxycodone for severe pain. Despite pharmacy records showing regular deliveries of Oxycodone, staff discovered that a full card of the medication was missing, with only seven doses documented as administered out of thirty delivered. The controlled substance administration records and inventory count sheets for this medication were also missing, making it impossible to determine the exact amount unaccounted for. Staff communications revealed that concerns about the missing narcotics were reported to management, but there was no timely response or follow-up from supervisory staff. Additionally, a discrepancy was identified with another resident's Alprazolam delivery, where 45 tablets were delivered but only one card and one administration sheet were signed in, instead of the required two. This error in documentation could allow for medication to be removed without detection. Multiple staff interviews confirmed ongoing issues with narcotic counts and documentation, particularly involving the same nurse, and that these discrepancies were not properly identified during shift change counts. Staff also reported that missing narcotics had been an issue in the past, and that management did not conduct thorough interviews or investigations with all involved staff members. The facility's policy required that all allegations of misappropriation of resident property, including missing narcotics, be reported to the State Survey Agency within 24 hours. However, there was no evidence that the facility reported the missing narcotics to the State Survey Agency in a timely manner. Interviews with facility leadership confirmed that the incident was not reported as required, and that the investigation into the missing medications was incomplete, with no summary or conclusion documented.