F0609

D

Failure to Timely Report Alleged Misappropriation of Controlled Pain Medication

Sault Ste. Marie, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime related to misappropriation of a resident’s controlled pain medication. A cognitively intact resident, admitted with a left tibia/fibula fracture and prescribed hydrocodone/acetaminophen for pain, reported that a night shift nurse had taken four of her hydrocodone 10 mg/325 mg tablets, which she had brought from home in her purse. The resident stated this concern to staff at approximately 5:30 PM on a Saturday, and the DON documented in a progress note that the administrator and a nurse spoke with the resident about the missing Norco. Despite this allegation of misappropriation of narcotic medication, the NHA acknowledged in an interview that the allegation was not reported to the state agency at that time.

The deficiency was further supported by the timing of the report to the state agency compared with when the allegation was known to facility staff. The state agency report, dated 2/8/26 at 4:47 PM, listed the misappropriation incident as discovered on 2/7/26 at 5:26 PM, indicating late reporting. The resident had already reported the missing medication to the surveyor on 2/7/26 at 2:15 PM, and the surveyor alerted the DON at 2:20 PM that same day. Facility policy on Abuse, Neglect, and Exploitation required reporting all violations to the administrator, state agency, adult protective services, and other required agencies within specified timeframes, including not later than 24 hours for events that do not involve abuse and do not result in serious bodily injury. The facility did not follow this policy or the requirements of section 1150B of the Act in reporting the reasonable suspicion of a crime involving misappropriation of the resident’s property.