Failure to Investigate and Report Alleged Drug Diversion and Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, and injury of unknown origin were thoroughly investigated and reported to the State Survey Agency within five working days, as required. Specifically, the Administrator did not conduct a comprehensive investigation or report the results to the state agency following multiple allegations of drug theft and misappropriation of resident property by a medication aide. Despite receiving numerous anonymous complaints and law enforcement involvement, there was no documentation of staff or resident interviews, medication audits, or evidence of law enforcement notification. The accused staff member was not suspended or reassigned during the investigation, and the facility did not submit any Facility Reported Incidents regarding the alleged misappropriation. Additionally, the facility failed to report and thoroughly investigate the theft of 80 controlled substance tablets intended for the automated dispensing system. The medications were left unattended at the nursing station and subsequently went missing. The facility's response included limited drug testing of certain staff, but not all individuals with access to the area were tested, and there was no assessment of residents for potential ingestion or side effects. The investigation did not include a thorough search of personal belongings or interviews with all relevant parties, and the incident was not reported to the state survey agency because the medications were not assigned to a specific resident. Facility policies required prompt and thorough investigation of all allegations of theft or misappropriation, including interviews with all involved parties and notification of appropriate agencies. However, these procedures were not followed in the cases described. The Administrator acknowledged that the investigation and documentation were incomplete and that reporting requirements were not met, resulting in a lack of thorough investigation and failure to notify the state agency as required.