Failure to Thoroughly Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation involving one resident. The cognitively intact resident, who had multiple medical diagnoses including muscle wasting and atrophy, COPD, hypotension, severe sepsis, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, CHF, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder, reported that his medications were being taken while he was being transported to the hospital. The facility submitted a Self-Reported Incident indicating that a thorough investigation had been completed and the allegation was unsubstantiated. However, review of the facility’s investigation packet revealed there were no staff interview statements and no documented interview with the resident to determine which medications were allegedly taken, when they were taken, or to obtain other specific information about the allegation. The DON and a Unit Manager confirmed that no staff interview statements were documented and that no formal statement was obtained from the resident before he left for the hospital, nor was he contacted or interviewed at the hospital. These omissions were inconsistent with the facility’s own policy, which requires thorough documentation and investigation steps including interviews with the resident, reporter, staff on all shifts, and others, as well as complete documentation of findings.
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