§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.
§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
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Observations:
Based on facility policy, interviews, and record reviews, the facility failed to conduct a thorough investigation into an allegation of drug misappropriation and to protect residents from misappropriation of controlled substances for two of two residents reviewed. (Residents R1 and R2)
Findings include:
Review of Facility Policytitled Abuse (Revised June 1, 2025) defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services necessary to maintain physical, mental, and psychosocial well-being.
Continued review of the policy defines misappropriation of resident property as: "The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residents belongings or money without the residents consent. The facility policy further states that all reports of abuse, neglect, exploitation, and misappropriation must be promptly and thoroughly investigated. When a crime is suspected, staff must preserve evidence and handle materials carefully to avoid compromising any potential criminal investigation.
Review of facility documentation submitted to the Department of Health revealed that on July 31, 2025, at approximately 2:00 PM, a licensed nurse Employee E3 identified a discrepancy involving the medications of Resident R1 and Resident R2. Two medications were reported missing. At the time of discovery, Residents R2 had been discharged on July 30, 2025, while the other remained admitted. According to the nurses testimony, the overnight nurse administered only one narcotic during her shift. Suboxone (a medication used to treat opioid dependence) was last administered at 6:00 AM and documented both in the narcotic count book and the electronic medication administration record (eMAR). Resident R2's Oxycodone (opioid pain medication) was last administered prior to her discharge on July 30, 2025. During the shift change, the overnight licensed nurse, Employee E4 conducted a medication count with the oncoming 7:00 AM3:00 PM Licensed nurse Employee E3. Both nurses confirmed that the narcotic count was complete and accurate at the time of the 7:30 AM handoff.
Review of Facility's Investigation revealed three staff statements were obtained, a basic audit of all six medication carts was completed, revealing no additional discrepancies. Continued review of facility investigation included, medical provider notified, replacement medications were ordered, and the local police department was notified.
However, the investigation lacked critical elements: No Inventory Reconciliation was documented/performed, there were no documented medication counts included, no waste documentation was provided, interviews were conducted with only three employees not all staff who had access to the medication cart, and the exact count and accounting of the missing drugs were not documented, the missing medications (9 Suboxone films and 10 Oxycodone tablets) were only mentioned during interviews and were not documented in the investigation report.
Review of Licensed nurse, Employee E5 (Nursing Supervisor) written statement dated July 31, 2025, stated that on July 30, 2025, during the 11 PM7 AM shift, a resident expired at 5:33 AM. The charge nurse, Employee E4, was instructed to secure the deceased residents medications. The nurse claimed the only medication present was one full blister pack of Lisinopril, and no discrepancies were reported at that time.
Review of Licensed nurse, Employee E3 's written statement dated July31, 2025, reported that she conducted a medication count with the morning nurse and did not recall counting Oxycodone or Suboxone. When this discrepancy was noticed, the Director of Nursing (DON) was immediately notified.
Review of Licensed nurse, Employee E4's written statement dated July 31, 2025, indicated proper narcotic counts were conducted at the start and end of shift. The only narcotic administered was one dose of Suboxone at 6:00 AM.
Review of employee E 4 Personnel File revealed that the license was verified as current and the criminal background check was marked as pending. NursingHome Administrator (Employee E1) provided the completed background check only after it was requested by the surveyor.
Review of provided medication carts audit revealed the audit documentation included basic charting of dates, locations, insulin vial status, presence of loose pills, and need for follow-up, but did not include any actual narcotic counts.
Interview with Director of Nursing, Employee E 2 on September 2, 2025, at 10:20 a.m.revealed that the Investigaton determined that licensed nurse Employee E4 was responsible for the missing medications. This employee is not an employee of the facility but an agency nurse. She has worked at the facility twice. Employee E2 concluded that the nurse manipulated the pages of the narcotic book to indicate an inaccurate about of medication that were counted. This overnight nurse was not charged but noted on a do not return list of the facility. Continued interview with Employee E2 revealed that he conducted a full audit" of all medication carts and determined no other medication were missing. Education was given to employees, and policy were altered going forward. Employee E2 confirmed that the provided documents of the medication audits were incomplete the documents did not reflect the actual count of medication, and no other staff were interviewed. Further interview with this employee indicated that the investigation was determined completed but documentation was not included.
28 Pa. Code 211.9(a)(1) Pharmacy Services
28 Pa. Code 201.149A) Responsibility of Licensee
28 Pa. Code 201.18(a)(j)(4) Management
| | Plan of Correction - To be completed: 10/01/2025
Immediate Corrective Action: Investigation was conducted and concluded including missing documentation. Facility covered the cost of medications for R1 and R2. Misappropriation was unsubstantiated.
Housewide Corrective Action: A 30 day look back was completed of reportable events to ensure a complete and thorough investigation was completed.
Policy/Education: NHA, DON and ADON will be re-educated on facility's Abuse policy.
Performance Monitoring: NHA or designee will complete weekly audits x 4 and monthly audits x 2 of reportable event to ensure a complete and thorough investigation was conducted. Results will be reviewed during facilities monthly QAPI meeting. QA meeting will determine the need for continued auditing.
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