Incomplete Investigation of Medication Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a complete and accurate investigation into an allegation of misappropriation of medication for a resident who was cognitively intact and admitted with ambulatory dysfunction due to a prosthetic joint infection. The resident reported not receiving prescribed PRN Oxycodone after requesting it from both a female nurse and a female aide during the night, with conflicting information later indicating a male nurse may have been involved. The facility's policy required that all allegations of misappropriation be thoroughly investigated, including identifying and interviewing all involved staff and witnesses, and obtaining written statements from them. Despite these requirements, the facility did not identify the staff members referenced by the resident, nor did it document efforts to determine their identities or reconcile the inconsistencies in the resident's account. The investigation included only a single witness statement from an LPN who was not directly involved in the medication administration. There was no evidence that the staff who documented administering the medication were interviewed or provided written statements. This incomplete investigation did not substantiate or disprove the resident's allegation, failing to meet the facility's own investigative standards.