Failure to Protect Residents and Investigate Missing Narcotics
Penalty
Summary
The facility failed to ensure the protection of residents during the investigation of alleged resident-to-resident abuse and did not thoroughly investigate an allegation of missing narcotics. In the case of a resident with a history of sexually inappropriate behavior, the care plan included interventions such as 1:1 supervision and frequent safety checks. However, after an incident where this resident was observed inappropriately touching another resident, documentation and staff interviews revealed that 1:1 supervision was not consistently provided, and records were falsified to indicate supervision had occurred when it had not. There were gaps in supervision, and staff responsible for 1:1 care did not complete or initial the required documentation, resulting in periods where residents were not protected as required. Regarding the missing narcotics, the facility failed to maintain accurate records and conduct a thorough investigation into the disappearance of controlled substances, specifically Oxycodone and Alprazolam, for two residents. Staff discovered discrepancies in the narcotic count sheets and administration records, with missing documentation and unaccounted-for medication. Despite reports to management, there was a lack of timely response and follow-up, and the facility was unable to determine the amount of medication missing due to incomplete records. Interviews with staff indicated ongoing issues with narcotic accountability, and some staff expressed reluctance to work in certain areas due to frequent incidents of missing medications. The facility's policies required prompt and thorough investigation of abuse and misappropriation of resident property, including maintaining evidence and documentation. However, the investigation into both the abuse incident and the missing narcotics was incomplete, with missing records, lack of documentation in resident progress notes, and no clear summary or conclusion of the investigations. The failure to provide required supervision and to maintain accurate medication records directly affected the safety and well-being of the residents involved.