Failure to Report Misappropriation of Narcotic Medications to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely and completely report suspected misappropriation of narcotic medications to the State Agency and other required authorities. For one resident with immobility and contractures who had an order for oxycodone 5 mg twice daily, pharmacy documentation showed two 30‑tablet cards of oxycodone were delivered, but only one card (labeled 1 of 2) was present in the locked narcotic drawer when a medication aide and a nurse counted narcotics at shift change. The missing 30‑tablet card was reported to the DON, who stated she submitted a 24‑hour report to the State Agency and notified law enforcement, Adult Protective Services, and the contracted pharmacist. However, she could not produce a 5‑day investigation report or proof it was sent, and the State Agency did not receive it, contrary to the facility’s Abuse Policy requiring reporting of misappropriation to the State Agency, Adult Protective Services, and law enforcement within 24 hours and completion of a 5‑day investigation report. The deficiency also includes the facility’s failure to report another incident of missing narcotics for a hospice resident with osteoporosis and chronic pain who had PRN oxycodone 5 mg and scheduled morphine sulfate. Pharmacy delivery records showed oxycodone tablets were supplied, and a medication aide recalled 28 oxycodone tablets present in the locked narcotic drawer on a prior workday. When asked by a hospice nurse to count narcotics, the aide found that the oxycodone card with 28 tablets was no longer in the locked narcotics box and reported this to the DON. The DON acknowledged that she did not initiate a 24‑hour or 5‑day report to the State Agency and did not notify police, Adult Protective Services, or the DEA about the 28 missing oxycodone tablets, stating she believed additional reporting was unnecessary because she had already investigated the earlier missing oxycodone for another resident. The administrator stated the DON should have ensured required notifications were made for both residents’ missing narcotics.
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