Failure to Report Unauthorized Administration of Controlled Substance to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of a crime toward a resident to the state survey agency and local law enforcement within the required 2-hour timeframe. Facility policy dated 10/11/22 required all allegations of abuse, neglect, misappropriation of resident property, exploitation, injuries of unknown source, and suspected criminal acts to be reported to appropriate authorities within required time frames. Resident #4 had a quarterly assessment dated 04/18/25 showing a BIMS score of 12, indicating moderate cognitive impairment. On 06/24/25, a Transfer to Hospital Summary documented that the resident was transferred due to increased confusion, hallucinations, shortness of breath, and abdominal breathing of 30 breaths per minute, and that the nurse had informed the hospital that the resident had received one-half of a Xanax tablet from a family member. Review of the resident’s EMR and medication records showed there was no order for Xanax for this resident. During interviews, one LPN stated that during a lunch break a family member told them they had given the resident one of their own Xanax tablets because the resident was yelling out for their deceased husband. The LPN reported that they informed another LPN, who was arranging the resident’s transfer to the hospital, about the Xanax, and that ambulance staff were notified. The second LPN recalled being informed that a specific family member had given the medication, and stated they called that family member, who confirmed giving the tablet and explained why. The administrator stated they were informed of the incident by the DON at the time, and that they and the corporate nurse discussed whether to report it but decided it was not reportable because there was no place for such an incident on the state incident reporting form. The administrator later acknowledged that if someone administered their personal controlled substance to a resident, it should have been reported as a criminal activity and that they had not fully followed the facility’s abuse policy.
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