Failure to Report and Investigate Alleged Misappropriation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate allegations of misappropriation of resident property, specifically missing controlled substances, for five residents. Facility policy on Abuse, Neglect, & Exploitation required written procedures prohibiting misappropriation of resident property, and the Medication Ordering and Receiving from Pharmacy policy required special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, review of clinical records and controlled substance records on multiple residents revealed discrepancies in narcotic counts and missing documentation, and the facility did not report these issues to the Department of Health as required. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed. Review of the controlled substance records showed that on specific dates, the documented doses and the beginning and ending counts for MS Contin 15 mg and 30 mg did not reconcile. Additionally, there was no controlled substance record for the ordered Oxycodone 5 mg as needed over more than a month, even though the pharmacy confirmed dispensing 18 tablets. Similar discrepancies were identified for another resident with coronary artery disease, COPD, and osteoarthritis, whose Oxycodone 7.5 mg as needed count decreased from 40 to 36 tablets over two days while documentation indicated only two tablets were administered. Further review showed that a resident with high blood pressure, depression, and spina bifida had MS Contin 15 mg three times daily with count discrepancies over two days, and another resident with high blood pressure, depression, and neuropathy had Oxycodone 5 mg as needed with a count that dropped from 12 to 9 tablets while only one tablet was documented as given. A fifth resident with heart failure, COPD, and muscle spasms had Oxycodone 10 mg three times daily, with records indicating four tablets given over two days while the count decreased from six to two tablets, and this resident was reported to have slept all night. Staff interviews described that an agency RN worked the overnight shift when the discrepancies occurred, appeared shaky and emotional, and could not adequately account for missing tablets. The RN supervisor and oncoming RN identified incorrect counts and documentation, notified the DON, and obtained a statement from the agency RN. However, the DON later acknowledged that no investigation of the alleged narcotic diversion was completed and that the incident was not reported to the Department of Health, confirming the facility’s failure to report allegations of misappropriation of resident belongings for the five affected residents.
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