Failure to Timely Report Alleged Abuse, Neglect, and Drug Diversion
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported immediately, or within the required timeframes, to the administrator and appropriate authorities. Specifically, the facility did not report to the State Survey Agency allegations of drug theft and misappropriation of resident property by a medication aide (MA A), nor did it report the theft of 80 controlled substance tablets that occurred when a licensed vocational nurse (LVN A) left medications unattended at the nursing station. Multiple anonymous complaints were received alleging that MA A was misappropriating resident medications and items, and a video surfaced showing MA A injecting herself with medication in the facility’s central supply closet. Despite these allegations and evidence, the facility did not submit any Facility Reported Incidents regarding MA A to the state agency, and MA A was not suspended or restricted from medication access during the investigation. In the case of the missing controlled substances, LVN A signed for a delivery of 80 controlled substance tablets, left them unattended at the nursing station, and later discovered them missing. The facility did not report this drug diversion to the State Survey Agency. Interviews revealed that the medications were left out for an extended period, and the facility’s investigation included drug testing only certain staff, searching common areas, and reviewing the incident, but did not include a comprehensive search or assessment of all individuals who may have had access. The facility’s leadership, including the Administrator and Regional Clinical Director, believed that the incident was not reportable because the medications were intended for the automated dispensing system and not for a specific resident. Facility policies required prompt and thorough investigation of theft or misappropriation of resident property, including notification of appropriate agencies within 24 hours and suspension of accused employees pending investigation. However, these policies were not followed in the cases involving MA A and LVN A. The Administrator and other leaders acknowledged that reporting requirements were not met, and that the facility did not fully investigate or report the incidents as required by federal and state regulations.