Failure to Report Missing Fentanyl Patches as Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of controlled substances to all required entities after two Fentanyl transdermal patches ordered for a resident went missing. The resident had diagnoses including hemiplegia and malignant neoplasms of the bladder and prostate and had impaired cognition, and had an active order for Fentanyl 50 mcg/hr patches for chronic pain. The investigation report showed that the former DON was notified by a night-shift LPN that two Fentanyl patches were missing. Interviews established that one LPN received a pharmacy delivery containing two Fentanyl patches, counted them, and signed the delivery slip, then handed the bag with the narcotics to another LPN. The receiving LPN stated she did not receive the two Fentanyl patches and was unaware she was supposed to have them. Another nurse confirmed the two Fentanyl patches were never found and stated they should have been reported as misappropriated. Further interviews revealed that the former DON acknowledged there were two missing Fentanyl patches for the resident and confirmed they should have been reported to the state agency via a Self-Reported Incident for misappropriation and to the police, but stated she was instructed by corporate and the Administrator not to report the incident, based on the rationale that the facility could not misappropriate its own property. The Regional RN did not know why an SRI was not completed and deferred to the Administrator. The pharmacist confirmed he was not notified of any missing narcotics, including the Fentanyl patches, and stated he should have been notified. Facility policies on abuse, neglect, exploitation, misappropriation of resident property, and controlled substances required immediate reporting of such allegations to the Administrator/designee, the state health department, and law enforcement when a crime is suspected, as well as consultation with pharmacy and the Administrator for controlled substance discrepancies. These required notifications and reporting steps were not carried out for the missing Fentanyl patches.
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