Incident investigation·May 3, 2023

On this day Licensing Program Analyst (LPA) conducted an unannounced case management visit in regards to missing narcotics. LPA met with interim administrator Jennifer Bruhn and explained the purpose of today's visit. Health care manager Jo Marie Ghersi attended the meeting as well to discuss the missing narcotics. It was reported to the Department on 05/01/2023 that over the weekend during routine medication check the Health care manager Jo Marie Ghersi was conducting an audit and discovered the missing narcotics beginning on 04/29/2023 and then again on 04/30/2023. According to Jo the final count of missing narcotics that were prescribed as needed. The facility did report accordingly to the Department on 05/01/2023 and followed with an incident report on 05/02/2023. The facility reported the loss to local Sheriff's Department and was provided a file number for the incident. The facility is actively investigating the situation which included additional medication audits, reviewing the medication administration records, as well as actively looking into their own staff. There is a discrepancy found by the health care manager regarding the crossover signatures on the days in question as being incomplete. The medications are accurately documented on the centrally stored medication log and for each resident. The narcotics are triple locked in the appropriate area of the medication room to ensure the are inaccessible to residents in care. The only persons with access are the staff. Residents' whose medication is missing did not miss any dosage of medication and the facility is replacing those missing items as necessary. Investigation into the matter is ongoing at this time. No citations at this time as this investigation is ongoing. Report is reviewed with interim administrator Jennifer Bruhn.