Failure to Timely Report Suspected Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to report a suspected misappropriation of a resident’s narcotic medication to the State Survey Agency within 24 hours as required by its own policy and federal and state regulations. The facility’s policy defined any event reported by a resident as an allegation of abuse, neglect, misappropriation of property, or exploitation, and specified that misappropriation included the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. The policy further required that all alleged violations involving misappropriation of resident property be reported immediately, or no later than 24 hours, to the Administrator and to other officials, including the State Survey Agency, and that investigative files be maintained as working documents of the Quality Improvement Committee. Despite these requirements, the facility did not report the allegation involving suspected diversion of narcotic medication for one resident to the State Survey Agency within the required timeframe. The resident involved was admitted with anxiety disorder, a right femur head fracture, and dementia, and had a BIMS score of 6/15, indicating severe cognitive impairment. An internal handwritten investigation document showed that on 11/04/2025 the Station 3 Unit Manager reported to the DON a concern about wasting a narcotic medication for this resident: the waste was witnessed by an LPN and an RN, but the concern was that the resident took pills whole while the waste presented for witnessing was a spilled crushed medication. On 11/05/2025 the DON informed the Administrator, and on 11/10/2025 an anonymous call was made to the company’s Values Line about the concern. A regional nurse later notified the DON that an anonymous Values Line call had been received regarding the RN and narcotics, prompting an internal investigation. Documentation from a regional nurse showed that over three days the RN documented administering six doses of oxycodone-acetaminophen to the resident, and a drug screen ordered by the Medical Director for the resident was negative for opiates. These events were known to the DON, ADON, Administrator, and others, but there is no indication that the suspected misappropriation was reported to the State Survey Agency within 24 hours as required.
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