Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication for one resident who was severely cognitively impaired and dependent on staff for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone. According to interviews and record review, a nurse did not enter the resident's room during her shift and informed a family member that the oncoming nurse would administer the medication. The oncoming nurse then reported that the medication was missing, although it had been documented as given. A certified nursing assistant notified the administrator of the situation, but the administrator did not follow up with the family member as promised and did not report the incident to the state health department or law enforcement, as required by the facility's abuse prevention policy.