Failure to Thoroughly Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation and possible diversion of narcotic medications for one resident. Facility policy required that all events reported as possible abuse, neglect, or misappropriation of resident property be investigated, and when in doubt, an investigation should be conducted. The resident involved had been admitted with a right femur head fracture, anxiety disorder, and dementia, and was assessed as having severely impaired cognition with a Brief Interview for Mental Status score of 6 out of 15. An initial concern arose when the Station 3 Unit Manager reported to the DON that a nurse had requested a witness for wasting a crushed medication for this resident, even though the resident took pills whole, and the Unit Manager also noted that one nurse appeared to be the only one administering the resident’s narcotic pain medication. Subsequently, an anonymous call was made to the company’s Values Line regarding concerns about a specific RN and narcotics, which was relayed to the DON and regional nursing staff. Documentation from a regional nurse showed that on three consecutive days, the same RN documented administering multiple doses of the resident’s PRN oxycodone-acetaminophen. The Medical Director was notified and an order for a drug screen for the resident was obtained. The Pharmacist, at the DON’s request, audited narcotic sheets on the cart and identified a pattern of significant wasting and frequent PRN use involving one particular nurse and select residents, and she reported these concerns to the DON. Despite these concerns and the facility’s own policy, the facility’s investigation was limited and lacked key components. The Administrator stated that the facility viewed the initial concern as a matter between employees and did not want to accuse someone without proof, and that review of MARs, narcotic sheets, and additional rounding had not raised red flags in their view. No staff interviews were conducted, and there was no documented evidence that residents were interviewed as part of the investigation. The Administrator also stated that a drug screen was not conducted on the implicated RN, and the facility’s documentation did not show that all required state agencies were notified. The survey found no documented evidence that a thorough investigation, consistent with policy and reporting requirements, was performed in response to the suspicion of narcotic misappropriation for this resident.
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