Failure to Document Thorough Investigation of Missing Medication
Penalty
Summary
The facility failed to maintain documented evidence of a thorough investigation into the alleged misappropriation of medication for one resident. According to facility policy, any suspected loss or discrepancy of medication requires immediate notification of the DON or supervisor, a thorough investigation, and documentation of the loss and investigation process. In this case, pharmacy records showed that 90 tablets of hydrocodone-acetaminophen were delivered for a resident with a history of colostomy, osteoarthritis, and rheumatoid arthritis, who was cognitively intact. However, the accountability record only accounted for 60 tablets, with no documentation for the remaining 30 tablets, despite the delivery records indicating a total of 90 tablets dispensed. Further review of the resident's records and facility documentation revealed that the missing 30 tablets could not be located, and there was no comprehensive documentation of the investigation process as required by policy. While the facility conducted an audit of narcotics and the consultant pharmacist reviewed medication records, there was no documentation of the audit itself or the residents reviewed. The investigation folder provided to surveyors contained only limited documentation, such as the initial notification, a five-day follow-up, a few witness statements, and some accountability records, but lacked evidence of a thorough and complete investigation into the missing medication.