Failure to Thoroughly Investigate Drug Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of drug misappropriation involving two residents. A discrepancy was identified by a licensed nurse regarding missing controlled substances—specifically, Suboxone and Oxycodone—after one resident had been discharged and another remained admitted. The overnight nurse reported administering only one narcotic during her shift, and both the narcotic count book and electronic medication administration record reflected this. During the shift change, the narcotic count was reportedly accurate, but subsequent investigation revealed missing medications. The facility's investigation included obtaining three staff statements, a basic audit of medication carts, notification of the medical provider, ordering replacement medications, and notifying the police. However, the investigation lacked critical elements such as documented inventory reconciliation, actual medication counts, waste documentation, and comprehensive staff interviews. The missing medications were only referenced in interviews and not formally documented in the investigation report. Further review showed that the medication cart audit did not include narcotic counts, and not all staff with access to the medication cart were interviewed. The Director of Nursing determined that an agency nurse, who had worked at the facility twice, was responsible for the missing medications, based on manipulation of the narcotic book. The agency nurse was not charged but was placed on a do-not-return list. The investigation documentation was incomplete, with missing records of medication counts and incomplete audit documentation. The facility's failure to thoroughly investigate and document the incident resulted in a deficiency under state pharmacy services and management regulations.