- Date
- 12/2/2015
- Report number
- OR0001034702
- Type
- Licensing Violation
- Level
- 1 - No harm or potential for minor harm
- Allegation
- Failure to provide a system that prevents theft or misuse of medication
- Result
- Substantiated
- Findings
- Failure to maintain a system for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administrered by the facility.4110540055(1)(e) On December 4, 2015, Staff 2 was interviewed to determine if there were any licensing systemic issues that led to errors in the reporting and documentation of narcotic medications. Staff 2 admitted that Staff 3 (who resigned on December 4, 2015) and Staff 1 were having challenges that contributed to overall oversight issues. Medication were not being administered to Resident 1 but were missing from Resident 1's MAR & medication cart. Since the discovery of missing medication, Staff 2 was sent from corporate office to assist Staff 1 in their internal investigation, narcotic audit and retraining of existing and replacement staff. Both Staff 1 & 2 have retrained all facility medical aides via inservice training and meetings in November 2015. On December 4, 2015, Staff 4 was interviewed and then shadowed during medication administration before lunch. Staff 4 explained that both Staff 1 & 2 have done oneoneone training with all medical aides in November 2015 to cover the basics and rules; reminding medical aides to sign medication out as they are administering them; reminding medical aides where to stand to observe residents taking medication; how to properly dispense medication; what to do with unused, old or partially used medication; how to properly document everything.Compliance Specialist (CS) observed Staff 4 administer all medications required before lunch and then observed Staff 4's record keeping and refilling medical cart with medication. On December 4, 2015, Staff 3 was interviewed and shared that this was his/her last day as he/she resigned. Staff 3 while clearing his/her office, accepted the interview and shared differences in opinions between Staff 3 and Staff 1. It became clear that both Staff 3 & 1 have been clashing for some time and as a result, gaps in communication and reporting ensued. Once the facility became aware medications were missing, Staff 1 selfreported the issue. Staff 2 was sent from corporate to help with an internal investigation, narcotic audit & retraining staff. Staff 1 & 3's differences could not be resolved so Staff 3 announced his/her resignation. Both Staff 1 & 3 point to each other as causes of the rift between them. This rift, helped create an opportunity (according to facility's internal investigation) for Staff 5 to steal Resident 1's medication for a period of time before thefts were discovered and reported.On December 16, 2015 Staff 1 & 2 were interviewed again to determine where the facility was with hiring someone to replace Staff 3. CS was informed that facility has been using someone from corporate to cover part time until a replacement was secured. A replacement has been hired but he/she is going through training through the end of December 2015. Staff 1 was also interviewed separately to determine all steps taken to prevent a systemwide breakdown that occurred in November 2015. Staff 1 indicated that Staff 5 resigned and has been replaced by fully trained staff; other medical aides were retrained on an oneonone basis; additionally, all medical aides pariticipated in a meeting where all oneonone training points were reviewed and discussed again.CS believes a new system is now in place for medication control and administering medication with clearer reporting lines should any medication disappear or is unaccounted for.