Failure to Investigate Suspected Narcotic Diversion
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of missing potential narcotic medication for one resident. According to the facility's policy, all discrepancies, suspected loss, or diversion of medications must be immediately investigated and reported. A review of clinical records showed that a resident with chronic pain syndrome had an order for oxycodone as needed for migraines. The Medication Administration Record (MAR) and controlled substance inventory sheets revealed that a single licensed nurse was signing out and administering the medication, with discrepancies noted on specific dates. The resident later stated they had not requested the medication, prompting suspicion of possible diversion. The unit manager identified inconsistencies between the narcotic book and the MAR and reported the issue to the DON when the medication was discontinued. Despite the suspicion of medication diversion, the DON confirmed that no investigation was initiated at the time the concern was reported, as the administrator was out of the office and the nurse in question was not scheduled to return for several days. An investigation was only started after a subsequent, similar allegation involving another resident. The failure to promptly investigate the initial suspicion of narcotic diversion constituted a violation of facility policy and state regulations.