Failure to Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy requiring immediate and thorough investigation of alleged misappropriation of resident property, specifically narcotic medication. A cognitively intact resident, admitted with a left tibia/fibula fracture, reported that a night shift nurse took four hydrocodone/acetaminophen tablets that the resident stated she had brought from the hospital and kept in her purse. The resident reported increased pain and a desire to take one of the missing pills. A progress note by the DON documented that the resident had raised the concern about four missing Norco tablets in her purse. The facility’s written policy required immediate investigation of suspected abuse, neglect, exploitation, or misappropriation, including investigating different types of alleged violations, identifying and interviewing all involved persons and potential witnesses, and providing complete and thorough documentation of the investigation. Surveyor review and interviews showed that these investigative steps were not carried out as required. When asked on multiple occasions, the DON could not initially provide documentation of an investigation into the alleged misappropriation of narcotics. Later, a summary of the event was produced by the RDO, but review of staff interviews and staffing schedules revealed that 16 staff members who could have relevant information were not interviewed regarding the allegation. Additionally, the DON stated she was unsure whether nurses asked about medications during the admission process and only knew that care assistants inventoried clothing, indicating that resident medications were not consistently inventoried on admission. This lack of comprehensive interviews, incomplete documentation, and absence of a clear process for identifying and accounting for resident medications on admission demonstrated the facility’s failure to follow its own policies and procedures for investigating alleged misappropriation of resident property.
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