Failure to Timely Report Alleged Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to report an allegation of misappropriation of a resident’s narcotic medication to the state agency within the required 24-hour timeframe. The facility’s Abuse Prohibition Protocol Manual requires the Administrator or designee to report allegations to the State Survey Agency within two hours if abuse or serious bodily injury is involved, or within 24 hours if the event did not involve abuse or serious bodily injury. Resident #1’s quarterly MDS dated 12/25/25 showed the resident was moderately cognitively impaired, received PRN pain medication during the seven-day look-back period, and used an opioid medication. The resident’s POS for 10/01/25–10/31/25 included an order for Morphine concentrate solution 100 mg/5 ml every four hours as needed for pain. During a narcotic count in October, an LPN observed that Resident #1’s liquid Morphine bottle, received in June, had a broken seal and the liquid appeared clear instead of the expected pink color, leading the LPN to believe the bottle was full of water. The LPN reported this to the ADON. The pharmacist later confirmed that the Morphine solution should remain pink and that water entering the bottle would dilute the color. The ADON stated that the LPN reported the potential missing doses and possible misappropriation to him/her, and that he/she then reported this potential misappropriation to the Administrator. The Administrator and ADON both acknowledged that the Administrator was responsible for reporting allegations of misappropriation of property to the Department of Health and Senior Services within 24 hours, but the Administrator did not remember if DHSS was contacted, and the ADON did not know if the allegation was reported. The DON, who was not employed at the time of the incident, confirmed that staff are directed to report abuse and neglect immediately to a supervisor or the Administrator and that the Administrator is responsible for reporting misappropriation allegations to DHSS within 24 hours.
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