| 81 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2019-03-08 |
609 |
D |
0 |
1 |
SJ2F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility administration failed to report missing narcotic medication concerns to the required State Survey Agency. The failure had the potential to affect any resident having narcotics delivered or stored at the facility, and this failure increased the risk of misappropriation of resident property related to narcotic medications, due to the lack of thorough management and tracking of missing medications. Findings include: During an interview on 3/7/19 at 10:00 a.m., staff member C was outlining the facility practice for the accounting and security of controlled substances. During the conversation, staff member C stated, We had one episode of a missing controlled substance reported to the DE[NAME] Medication was sent back to pharmacy for re-labeling, and the card [MEDICATION NAME](hypnotic) went missing. See F755 and F761 for event details. During an interview on 3/8/19 at 8:01 a.m., staff member B stated she misspoke the other day (3/7/19), when she said they did not have any issues with missing medications. Staff member B described an incident with missing [MEDICATION NAME] (for pain) and missing Ambien, which occurred on 11/16/18, stating they investigated the incident and reported it to the DE[NAME] Staff member B was asked if the facility reported the incident to the police, and the State Survey Agency, and she stated, No. A review of the facility policy, Loss of Controlled Substances at (facility name), not dated, showed, On 11/16/18, #28 [MEDICATION NAME]/APAP 5/325 and #5 [MEDICATION NAME] (for [MEDICAL CONDITION]) 5 mg were returned from TCN nursing to (facility name) Pharmacy to be relabeled with updated sig/instructions. Pharmacy staff state that these meds were placed in the pick-up basket and the basket was picked up by TCN nursing. Since this was not a dispense, no signature log was created for these meds. When nursing checked in the basket full of meds, the [MEDICATION NAME]/APAP and [MEDICATION NAME] were not in it . (sic) Review of the facility Abuse Policy, dated (MONTH) (YEAR), showed the following for reporting allegations of abuse: [NAME] Reporting and Response: It is the policy of (facility name) that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and Montana State Law. (Facility name) will ensure that all alleged violations involving abuse, neglect, elopement, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. Abuse is reported no later than 24 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury, to the Director of Nursing or designee of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident at (facility name) . |
2020-09-01 |