Failure to Timely Report and Investigate Suspected Misappropriation of Medications
Penalty
Summary
The facility failed to report alleged violations of misappropriation involving six residents to the Illinois Department of Public Health (IDPH) within the required 24-hour timeframe and did not implement policies and procedures for reporting the possible crime to law enforcement. Video evidence showed an LPN sleeping in the medication room during her shift, dispensing medications from cards into her bare hands, and placing items in her mouth and pocket without referencing the Electronic Medication Administration Record (EMAR). Medication discrepancies were later discovered, and concerns about the LPN's behavior were reported by another nurse to the previous Director of Nursing (DON) the following morning. However, the initial concerns were not escalated immediately, and the facility did not recognize the misappropriation until a resident reported not receiving medications. The misappropriation was ultimately reported to IDPH and local police nine days after the facility began its investigation, rather than within the required reporting window. The facility's policy requires immediate notification of the Administrator and DON regarding any complaints, observations, or suspicions of resident abuse, mistreatment, or neglect, but this protocol was not followed. The delay in reporting and failure to implement established procedures resulted in a deficiency related to timely reporting and investigation of suspected abuse and misappropriation.