Failure to Report Suspected Medication Theft and Forgery
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the suspected forgery of staff signatures and the administration of controlled medications. Two residents were directly affected: one resident reported not receiving prescribed Norco pain medication on two occasions, despite documentation indicating it had been administered. The resident, who was cognitively intact, described experiencing severe pain after wound care and being told by a nurse that she could not receive additional medication due to records showing it had already been given. Review of the medication administration records and controlled drug logs revealed discrepancies, including doses signed out but not documented as administered. Multiple staff members, including LPNs and RNs, reported concerns about signatures being forged on controlled drug records and medications being signed out without being administered to residents. These concerns were reported to supervisors and the DON, with some staff specifically noting that their signatures appeared on records for dates they did not work or did not administer medication. Despite these reports and ongoing suspicions since at least May, there was no evidence that the facility reported these allegations of forgery and potential medication diversion to the State Agency or law enforcement, as required by facility policy and federal regulations. The facility's own abuse and neglect policy mandates immediate reporting of all allegations or suspicions of abuse, including potential crimes such as medication theft or forgery, to both the State Agency and law enforcement. The policy also requires a final investigation report to be submitted within five working days. However, the investigation file provided by the facility did not contain documentation of such reports being made, nor was there evidence that the allegations were communicated to the appropriate authorities within the required timeframes.