Failure to Timely Report Missing Narcotics as Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of misappropriation of property, specifically missing narcotics for two residents, were reported to the State Survey Agency within the required 24-hour timeframe. On a Sunday, an agency LPN notified the DON about potentially missing or misplaced narcotics. The DON then informed the Administrator, and both met at the facility to investigate the issue. Despite the facility's policy requiring prompt reporting of suspected misappropriation, the DON did not report the incident to the state or the regional team as initially claimed. The missing medications, identified as oxycodone/APAP tablets belonging to two residents, were not located, although all residents continued to receive their pain medications as ordered. Interviews with staff, including RNs, CMTs, and administrative personnel, revealed a general understanding that missing narcotics should be reported to the DON and to the state agency within a short timeframe, ranging from two to four hours. However, the DON and Administrator decided not to report the incident immediately, believing it was not a two-hour reportable event since it did not involve abuse. The misappropriation was ultimately reported to the state several days after the initial discovery, contrary to facility policy and regulatory requirements.