| 80 |
GATEWAY TRANSITIONAL CARE CENTER |
135011 |
527 MEMORIAL DRIVE |
POCATELLO |
ID |
83201 |
2018-04-12 |
835 |
F |
1 |
0 |
0IO011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and review of personnel files, a police report, and facility investigations, it was determined facility administration allowed a staff member, who was suspended from the facility for diversion of narcotics, to return to work when the administration had knowledge the staff member had misappropriated a resident's medication. This was true for 1 of 2 employees (Staff #A) whose personnel files were reviewed. The failure directly impacted 1 of 7 (#9) sample residents residing in the facility and placed the other 74 residents residing in the facility at risk of misappropriation of medications. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A Physician's verbal order, dated 11/21/17, documented Resident #9's [MEDICATION NAME] 10 mg every four hours as needed for pain was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented that on 11/27/17 it was reported to the DNS that during an attempt to dispose of a discontinued narcotic, one of Resident #9's medication cards had medications taped back into the card. The DNS identified Staff #A as the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented that Staff #A was interviewed on 11/30/17 at 2:00 PM, at which time Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replaced the remaining 11 doses in the bubble pack card with [MEDICATION NAME]. The investigation documented Staff #A was taking the [MEDICATION NAME] from Resident #9 for personal use since the beginning of November. Staff #A was suspended pending investigation. On 4/11/18 at 1:00 PM, the facility provided a current employee job profile that listed Staff #A as an LPN. The investigation summary documented the police department was notified on 12/1/17, four days after the misappropriation of Resident #9's controlled medication by Staff #A was reported to the DNS on 11/27/17. On 4/16/18, the facility provided a Police Department Detail Incident Report, dated 12/1/17. The report documented a police officer responded to the facility regarding a reported theft of medication. The police report documented a police officer spoke to Staff #A on 12/2/17 and Staff #A, .admitted to taking the pills between 11/14/17 and 11/17/17 .she had taken at least eleven [MEDICATION NAME] pills, possible (sic) more, though she did not remember the exact amount .she had taken the pills for personal use, and had already consumed them. The report documented the incident was forwarded to the narcotics division. The police report documented on 12/21/17 the narcotics division was not mandated to press a charge for the theft of the [MEDICATION NAME]. On 4/11/18 at 4:25 PM, the DNS stated Staff #A told him that she was in a program for recovering nurses. The DNS was unable to provide documentation about the recovering nurses' program and was unaware of any restrictions or limitations for Staff #[NAME] The DNS stated Staff #A was not working as a nurse, was not providing direct patient care, did not have access to the electronic medication records, and did not have keys to access the medication carts or medication rooms. The DNS stated Staff #A returned to work in (MONTH) under his supervision and her job duties were filing paperwork. Staff #A's employee time record documented Staff #A returned to work 2/12/18 through 4/9/18 and worked 4-5 days per week. On 4/12/18 at 10:00 AM, the DNS stated Staff #A filed paperwork in his office or in the charge nurse room within the conference room when he was in the building. The DNS provided a Program For Recovering Nurses (PRN) contract for Staff #A dated 1/7/18. Staff #A signed the contract on 1/7/18 and the witness signed the contract five days later on 1/12/18. The DNS stated he did not have the PRN contract until 4/12/18 and he was unaware that written approval from the PRN program was required for Staff #A to return to work in any capacity. The PRN contract signed by Staff #A documented, I shall not return to work until I receive written approval from the PRN and support of my treatment provider. In the event that I change positions or seek new employment, I shall obtain approval from the PRN at least two weeks prior to accepting the position. To begin working, I must first have a work monitor in place and all releases must be signed for the hiring facility. On 4/12/18 at 10:30 AM, the DNS stated he was unaware Staff #A had worked 3 of 5 Saturdays in (MONTH) (YEAR) (3/17/18, 3/24/18, and 3/31/18). The DNS stated he was not in the facility and Staff #A was not supervised on those dates. The untitled facility's investigation, dated 12/8/17, documented the results of the investigation determined, we feel this was an isolated incident that began in the beginning of November, involved one resident, and did not result in bodily harm or any adverse effect to the identified resident or other residents. The identified nurse was suspended, reported to the nursing board, and police were notified. The investigation was signed by the Administrator, DNS, and ADON. On 4/11/18 at 4:25 PM, the DNS stated Staff #A told him that she was in a rehab program for recovering nurses. The DNS did not recall the exact date and had no documentation when Staff #A shared this information with him. The DNS stated Staff #A returned to work on 2/12/18 to file paperwork only and was not providing direct patient care, did not have access to the electronic medication records, and did not have keys to access the medication carts or medication rooms. The DNS was unable to provide documentation of communication with the PRN program. The facility's current employee job profile documented Staff #A was listed as Licensed Practical Nurse. Staff #A's employee time records documented Staff #A returned to work on 2/12/18. On 4/12/18 at 8:45 AM, the DNS stated he called the rehab program on 4/11/18 and received a copy of the recovering nursing program for Staff #[NAME] The DNS provided a job description for Staff #A, dated 4/12/18, documented, Staff #A will do mostly clerical duties including but not limited to, filing paperwork for the director of nurses the assistant director of nurses, ward clerk, medical records and Human Resources. Staff #A will continue with these job descriptions/restrictions until further documentation can be verified that Staff #A has been approved and is improving with her monitoring program for the program of recovery nurses and the Idaho State Board of Nursing. The untitled document was signed by the Administrator and the DNS. The DNS stated Staff #A had not reviewed or signed the job description. On 4/12/18 at 10:00 AM, the DNS stated Staff #A verbally told the DNS she was in PRN program and she returned to work on 2/12/18, filing paperwork with under direct supervision with the ADON or DNS in the their office. The DNS stated he did not receive documentation or have communication from the recovering nursing program. The DNS provided a contract from the PRN program that he received on 4/12/18. On 4/12/18 at 7:50 PM, the Administrator stated the DNS notified the Board of Nursing via phone on 12/1/17 regarding the misappropriation of Resident #9's [MEDICATION NAME] by Staff #[NAME] The Administrator was unable to provide documentation the Board of Nursing was notified. The Administrator was not aware Staff #A was working in the facility unsupervised on 3/17/18, 3/24/18, and 3/31/18. The Administrator was unable to provide documentation of communication with the PRN program regarding Staff #[NAME] The Administrator stated the investigation was completed under the direction of their corporation and he thought it was complete. The Administrator stated the investigation could use some improvement looking back on it now. 2. Also refer to: * F602 as it relates to the facility's failure to ensure residents were free from misappropriation of a controlled medication. * F608 as it relates to the facility's failure to ensure the facility reported misappropriation of medications to law enforcement within 24 hours. * F609 as it relates to the facility's failure to ensure the facility failed to report the misappropriation of medications to the State Survey Agency within 24 hours. |
2020-09-01 |