Failure to Immediately Report Suspected Misappropriation of Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the Illinois Department of Public Health (IDPH) and local law enforcement of suspected misappropriation of a resident’s controlled medication. Record review showed that on 2/2/26 the Administrator (V1) was notified that a resident’s oxycodone could not be refilled by the pharmacy because it would be refilled too soon, prompting concern for a potentially missing card of oxycodone. An internal investigation into unaccounted-for controlled medication was initiated on 2/6/26, and the Administrator was unable to locate the card. Despite this, the facility’s initial report to the IDPH Regional Office was not made until 2/10/26, and local law enforcement was also not notified until 2/10/26. Interviews confirmed that facility leadership recognized the missing oxycodone as misappropriation of resident property and acknowledged that it should have been reported immediately to IDPH and the police. The President of Operations (V5) stated that she was notified on 2/6/26 that the resident’s oxycodone was missing and that it was considered misappropriation, yet it was not reported at that time. The Administrator later stated that theft is to be reported immediately to IDPH and the police. The facility’s Abuse Prevention Program policy, dated 10/2023, requires contacting local law enforcement when there is reasonable suspicion that a crime has been committed in the facility by a person other than a resident. These findings show that, although there was reasonable suspicion of drug diversion and misappropriation of a resident’s oxycodone, the required immediate notifications to IDPH and law enforcement were delayed.
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