Failure to Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an allegation of misappropriation of a resident’s narcotic medication. The facility’s Abuse Prohibition Protocol Manual requires that all alleged violations of abuse, neglect, misappropriation, or exploitation be thoroughly investigated with documented evidence such as resident, witness, and staff statements, environmental review, resident physical assessment, and a clear timeline of events. The facility’s Narcotic Count policy further requires that any narcotic count discrepancy be reconciled with the off‑going nurse remaining on duty, the DON notified, and an investigation initiated to determine the cause of the discrepancy. Despite these policies, the medical record for the period reviewed contained no documentation that an investigation was conducted regarding the alleged misappropriation of the resident’s liquid morphine. The resident involved was assessed on a quarterly MDS as moderately cognitively impaired, having received PRN pain medication in the look‑back period, and using an opioid medication. The resident had an order for morphine concentrate solution 100 mg/5 ml to be given every four hours as needed for pain. An LPN reported that during a narcotic count, the seal on the resident’s liquid morphine bottle—received months earlier and reportedly never used—was found broken and the liquid appeared clear instead of the expected pink, leading the LPN to believe the bottle contained water. The LPN reported this to the ADON. The pharmacist later confirmed that morphine solution should remain pink and that dilution with water would lighten the color. The administrator stated that he and the ADON were responsible for thorough investigations of misappropriation allegations and that the ADON had investigated and found the allegation unsubstantiated; however, the ADON reported being unable to locate any paperwork related to this investigation, and the resident’s record contained no evidence of a completed investigation.
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