Failure to Timely Report Suspected Misappropriation of Narcotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to timely report a suspected misappropriation of a resident’s narcotic medication to the state survey agency as required by regulation and facility policy. The facility’s Abuse Investigation and Reporting policy required that all alleged violations, including misappropriation of property, be promptly reported to local, state, and federal agencies, with alleged misappropriation reported immediately but not later than two hours if involving abuse or serious bodily injury, or within 24 hours if not. The policy also required a written report of investigative findings within five working days. Despite these requirements, the facility did not report a missing card of oxycodone, a highly addictive pain medication, within the required timeframe after it was identified as missing. The resident involved had multiple medical conditions, including a right femur fracture, cognitive communication deficit, major depressive disorder, osteoarthritis of the knee, seizure disorder, and chronic pain, and was dependent on staff for ADLs and used a wheelchair. Hospital discharge orders included oxycodone 5 mg every eight hours as needed, and the physician order sheet later reflected oxycodone 5 mg every four hours as needed. On one occasion, an RN removed three 5 mg oxycodone tablets from the emergency kit for the resident and documented administration of only one tablet on the MAR, with no documentation in the record regarding the disposition of the other two tablets. Pharmacy records showed three cards (180 tablets) of oxycodone had been delivered for the resident. On a later date, an LPN, during narcotic count, noticed that one of three oxycodone cards for the resident was missing and that the narcotic count sheet page for that card was folded over, a practice used when a card is empty or destroyed, but with no documentation indicating destruction or return. The LPN reported the missing card to the ADON, and the DON confirmed with the pharmacy that three cards had been delivered. The Administrator later stated that missing medications should be reported to the state survey agency within two hours of being noted missing and acknowledged that the missing medications should have been reported when they were first identified as missing. The NP reported not being notified of the missing medication until weeks later. The facility’s failure to report the suspected misappropriation of the resident’s oxycodone to the state survey agency within the required timeframe constituted the cited deficiency.
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