Failure to Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of medication for one resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone to be administered every four hours. The resident's family member reported that the resident did not receive her medications on a specific date. The administrator reviewed video footage and checked the Medication Administration Records (MARs), which indicated the medications had been given, and concluded the issue was resolved without further investigation. Despite the family member's report that the nurse did not enter the resident's room and that the oncoming nurse stated the medications were missing but documented as given, the administrator did not notify the Director of Nursing or the Vice President of Clinical Operations, nor did she conduct a formal investigation as outlined in the facility's abuse prevention policy. The policy requires prompt and thorough investigation of all reports of misappropriation, including checking medication counts and documentation, and reporting findings to appropriate agencies. The failure to follow these procedures resulted in the deficiency.