Failure to Timely and Completely Report Alleged Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to timely and completely report two separate allegations of misappropriation of residents' narcotic pain medications. In the first incident, a facility reportable incident form dated 1/23/26 at 1:15 p.m. was provided, but the sections for the resident involved and the staff involved were left blank. Eight days after the initial allegation was reported to the Administrator, the brief description was completed, documenting that on 1/23/26 at 1:25 p.m. a QMA reported calling the pharmacy for a refill of a resident's oxycodone 10 mg/325 mg, and the pharmacy indicated it was too early to refill and that the resident should have had 40 tablets at the facility. The QMA reported that the DON had removed the medication from the medication cart earlier in the shift. The type of injury was documented as not applicable, and the immediate action taken section indicated the DON was suspended pending investigation. The follow-up section, dated 2/5/26, stated the facility was unable to substantiate the allegation of misappropriation. In the second incident, a facility reportable incident form dated 2/17/26 at 10:45 p.m. was also missing the names of the resident involved and the staff involved. The brief description, dated 2/18/26, indicated that during routine controlled drug reconciliation at the beginning of a shift, a discrepancy was identified and immediately reported to the ADON and the Administrator. The follow-up section, dated 3/5/26, indicated that the investigation had been completed and referenced personnel action, a complete audit of the medication cart, staff education, and ongoing audits. During an interview, the Administrator acknowledged that the staff and residents' names should have been included in each initial report, that misappropriation incidents should have been reported to the state health department within 24 hours, and that follow-ups should have been reported within five days of the incident. The facility’s Abuse Prevention and Prohibition Program policy stated that the facility promptly and thoroughly reports and investigates allegations of abuse.
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