Failure to Timely Report Suspected Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure that all allegations or suspicions of misappropriation of resident property, specifically medications, were reported to the State Survey Agency as required. In two separate cases, controlled medications prescribed to residents were found to be tampered with or missing, but the incidents were not reported in the required timeframe. In the first case, a resident with dementia, dysphagia, and a recent amputation had a prn order for liquid Morphine Sulfate, which was never documented as administered. A discrepancy was discovered when a nurse noticed the Morphine bottle contained less medication than expected, and a puncture hole was found in the seal. The DON was notified, and the Ohio Board of Pharmacy was involved, confirming that medication had been removed from the bottle. However, the DON did not submit a self-reporting incident (SRI) to the state survey agency until after the Board of Pharmacy's determination, acknowledging the report was not made within the required timeframe. A similar issue was identified with another resident who had a history of stroke, prostate cancer, and dementia, and was under hospice care. This resident's Morphine Sulfate bottle also had a puncture hole in the seal, and although the bottle appeared full, testing revealed the concentration of Morphine was significantly diluted, indicating that some medication had been removed and replaced with another solution. Again, there was no documentation of administration, and the DON did not report the suspicion of misappropriation to the state survey agency until after confirmation from the Board of Pharmacy, which was not within the required reporting period. Additionally, an investigation into this same resident's Oxycodone tablets revealed that several tablets had been removed from blister packs and replaced with Loratadine tablets. The tampering was discovered by a nurse and confirmed by the facility's contracted pharmacist, who identified slits in the packaging and mismatched tablets. Despite clear evidence that the resident's medication had been tampered with and replaced, the DON did not submit a self-reporting incident to the state survey agency, believing that proof of who took the medication was required. The facility's policy required immediate reporting of all allegations or suspicions of misappropriation, but this was not followed in these cases.