Incomplete Investigation of Missing Fentanyl Patches and Failure to Report Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into two missing Fentanyl transdermal patches prescribed for chronic pain for Resident #73, who had diagnoses including hemiplegia and malignant neoplasms of the bladder and prostate, and impaired cognition per the MDS. Physician orders directed application of a 50 mcg/hr Fentanyl patch every 72 hours. On the date of the incident, the former DON was notified by the night nurse of two missing Fentanyl patches, but the investigation documentation lacked basic elements such as the time of notification and complete staff statements. The investigation file contained only four statements from selected nursing staff and did not include a statement from the night LPN who initially reported the missing patches or from the LPN who oriented with the nurse that signed for the patches. The statement attributed to the LPN who received the pharmacy delivery was only present as an unsigned email from the Administrator. Only three staff members were drug tested two days after the incident, while other involved nurses, including the RN who counted narcotics with a day-shift LPN and the orienting LPN, were not tested. The former DON documented that the investigation was inconclusive and suggested the patches were likely disposed of when bags were thrown away, without supporting documentation. Multiple interviews confirmed that the two Fentanyl patches were never found and that the incident was not reported to the state survey agency via a Self-Reported Incident, to law enforcement, or to the pharmacy, despite facility policies requiring investigation and reporting of alleged misappropriation and controlled substance discrepancies. The pharmacist confirmed he was not notified of any missing narcotics and stated he should have been. The facility’s Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and Controlled Substances policy require immediate reporting of such allegations to the Administrator, ODH, and law enforcement when a crime is suspected, as well as consultation with pharmacy and documentation of the investigation. These policy requirements were not followed in this case, resulting in a deficient, incomplete investigation of the missing Fentanyl patches for Resident #73.
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