Failure to Report and Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of misappropriation of medication for a resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone every four hours. The resident's family member reported that the resident did not receive any medications during a specific shift, and video footage was reviewed by the administrator, who determined that the nurse had entered the room but did not verify medication administration. The Medication Administration Records (MARs) indicated that medications had been given, but the family member and oncoming nurse reported that the medications were missing and had been documented as administered. Despite the allegation and conflicting accounts, the administrator did not report the incident or initiate an investigation as required by the facility's abuse prevention policy. The Director of Nursing and the Vice President of Clinical Operations were not notified of the allegation, and standard procedures such as checking medication counts and narcotic logs were not followed. The facility's policy mandates prompt and thorough investigation of all reports of misappropriation, but this process was not initiated in this case.