Failure to Prevent Misappropriation and Ensure Proper Destruction of Controlled Medications
Summary
The deficiency involves the facility’s failure to protect residents’ medications from misappropriation and to ensure proper controlled substance handling and documentation. A facility-reported incident described that the former Unit A manager (an RN) removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a second licensed nurse witness the destruction. The RN then left work early without notifying the nurse responsible for that medication cart. When the assigned nurse later attempted to appropriately waste medications from the cart, she discovered the narcotics were already gone. She contacted another RN, who located the Controlled Dangerous Substance Destruction Report on the former unit manager’s desk, bearing signatures and initials of that RN and another staff member. When the other staff member was interviewed, he stated he was only aware of his own medications being wasted and not the additional two narcotics listed on the form. During the survey, narcotic logbooks on Unit A were reviewed and showed multiple days with missing entries (“holes”) in the logs. The current Unit A manager explained that the facility’s process required two licensed nurses to be present for the entire destruction process, from gathering the medications through signing paperwork and destroying the drugs. The DON acknowledged the prior incident involving the former unit manager and stated that the facility’s investigation could not determine which residents’ medications had been destroyed, although she noted that pharmacy could have been contacted using prescription numbers to obtain that information. Review of narcotic logs showed that some medications were documented as sent home with residents and others as destroyed, which the DON said was based on physician orders. When asked, the DON reported that the facility did not go back to verify whether narcotics were actually sent home or destroyed on Unit A during the former unit manager’s tenure and confirmed that the only step taken to determine whether other residents were affected was to verify that all medications were signed off in the records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and significant pain needs had an order for PRN oxycodone, and later two tablets were found missing from the resident’s oxycodone card and replaced with taped‑in pills that did not match the remaining tablets. During a shift‑change narcotic count, an LPN identified the non‑matching, taped‑in pills in two card slots, while another LPN acknowledged she had previously counted the narcotics without removing the card from the drawer. The facility’s investigation, as described by the RDCO, determined the substituted pills were melatonin and confirmed the oxycodone tablets were missing, but could not identify who took them or where they went, despite a policy stating that drug diversion is treated as misappropriation of resident property.
Multiple residents with cognitive impairment and complex medical conditions had their trust fund accounts used by former administrative and activities staff to make unauthorized online purchases of clothing, electronics, snacks, personal care items, and activity supplies. Required documentation and signatures authorizing withdrawals were absent, and some residents reported not requesting or receiving the items, while searches showed that certain items were missing or located in the activities department instead of with the residents. Former staff reported that they were informed when Medicaid residents’ balances exceeded allowable limits and then ordered items from an online retailer based on lists or general discussions, but without proper consent from residents or their representatives, resulting in misappropriation of resident funds and belongings.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Multiple cognitively intact residents with orders for opioid and gabapentin pain medications were affected when an agency RN on a night shift misappropriated controlled drugs and other medications. Pharmacy records showed oxycodone deliveries for two residents, but the corresponding controlled substance administration records were missing. During shift change, the agency RN reported having dropped and reorganized controlled substance cards and completed a count that initially appeared correct. Shortly after she left, oncoming LPNs discovered that a full card and additional tablets of oxycodone, as well as several cards of gabapentin, were missing, and that some doses were documented as wasted with cosignature initials that did not match any staff on duty. A second agency nurse denied assisting with reorganizing or wasting medications, and facility staff later confirmed the missing medications and irregular documentation, establishing that residents were not protected from misappropriation of their medications.
The facility failed to prevent tampering with and possible diversion of liquid morphine prescribed for three hospice residents with terminal conditions and cognitive impairment. Over several months, these residents had PRN morphine orders for pain and dyspnea, but records showed little to no documented administration and daily pain scores of zero. Multiple sealed morphine bottles assigned to two residents were later found with wet or smeared labels, reduced volumes compared to what should have been present, and, upon pharmacist inspection, puncture holes in the bottoms of the bottles. Some nurses signed off controlled substance counts as correct and did not report discrepancies, and law enforcement subsequently confirmed the bottles had been tampered with and opened an investigation.
A cognitively intact resident with multiple chronic conditions developed a personal relationship with a housekeeper who repeatedly discussed her financial problems and accepted money and use of the resident’s debit card for rent, car payments, household needs, and items for her children, while also using the card to buy snacks and personal items for the resident. Text messages showed the housekeeper acknowledging that the resident had given her "way too much" money, instructing him not to let anyone see him give her money, and emphasizing that no one could know they communicated outside of work. After the resident’s death, a friend and the resident’s daughter reported that the staff member had been taking money and attempting to access the resident’s debit card, and another resident reported knowing that the deceased resident had given his card to the housekeeper and paid some of her bills. These documented interactions demonstrated that the resident’s belongings and money were wrongfully used by staff.
Misappropriation and Undetected Diversion of Resident Opioid Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when two oxycodone tablets were missing from the resident’s prescribed opioid medication card and had been replaced with non‑matching pills. The resident had multiple serious medical conditions, including acute kidney failure, end‑stage renal disease, pleural effusion, hypertensive chronic kidney disease Stage V, diabetes, COPD, peripheral vascular disease, atrial flutter, and dependence on renal dialysis, and was care planned for pain related to chronic conditions and procedures. The resident’s orders included oxycodone 5 mg, two tablets every four hours as needed for pain, which was later discontinued. During a shift‑change narcotic count, two pills in the oxycodone card (in slots #2 and #6) were found taped into place, were not uniform in color, and were not scored like the other oxycodone tablets. One LPN reported that when she had counted the narcotics at the beginning of her shift, she did not remove the medications from the cart and only visually checked them in the drawer. Witness statements documented that on a prior count, the oxycodone card had no taped‑in medications, but at a later count the two taped‑in pills were present and did not match the remaining oxycodone tablets. The Regional Director of Clinical Operations stated that the facility’s investigation determined the two taped‑in medications were melatonin and that the two oxycodone tablets were missing, with no determination of who took them or where they went. The RDCO also stated that the pharmacy was notified of the missing oxycodone and that they inquired whether the resident was due any monies, despite the medication having been discontinued. When asked why the allegation of misappropriation was unsubstantiated, the RDCO could not provide an answer. Facility policy on controlled drugs and security stated that drug diversion would be treated as misappropriation of resident property and that the Board of Nursing would be notified as appropriate for known or suspected drug diversion after review and evidence collection.
Misappropriation and Unauthorized Use of Resident Trust Funds for Online Purchases
Penalty
Summary
The deficiency involves the misappropriation and unauthorized use of resident trust funds and belongings by former facility staff, including the former Business Office Manager (BOM), former Activities Director (AD), and former Social Services (SS) staff. Facility records showed that multiple residents had debits from their resident fund accounts for online retailer purchases that were not authorized by the residents or their representatives, and required documentation such as signed vouchers or check request forms was absent. The facility’s own abuse policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the documented actions of staff met this definition. One resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, had several online purchases charged to her resident funds account, including clothing and snack items, without authorization from her representative. Progress notes contained no documentation of these purchases by the former BOM, AD, or SS. The resident later confirmed that items had been purchased using his account and that he believed a television had been ordered but never received. The Administrator confirmed that the former AD made unauthorized online purchases from this resident’s account and that the facility could not verify that all items, including a cowboy outfit and other clothing, were provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional supplements. These purchases were not documented in progress notes and were not authorized by the resident or her representative. The resident reported that a cart of items was brought to her, including a new tablet and clothing she had not requested, and that she sent the items back. The Administrator verified that the former SS placed a substantial order under this resident’s name with the intent that the cost be withdrawn from her account, despite the lack of authorization. A resident with type 2 diabetes, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and required ADL assistance, had debits from his funds account for hearing aids and a television purchased through an online retailer. His representative had not authorized these purchases, and there was no documentation in progress notes of such purchases by the former BOM, AD, or SS. The Administrator confirmed that the former BOM and former AD used this resident’s funds to buy hearing aids and a television without authorization and that the television purchased for the resident was not in his possession and was suspected to be elsewhere in the facility. Another resident with epilepsy, end-stage renal disease, and aphasia following cerebral infarction, who was severely cognitively impaired and dependent for ADLs, had multiple online retailer debits from his resident funds account that were not authorized by his representative. Items purchased included a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks. There was no documentation in progress notes of these purchases by the former BOM, AD, or SS. The Administrator confirmed that these items were purchased without authorization, and a search of the resident’s room with his permission revealed that some of the items ordered were not present. A further resident with Alzheimer’s disease, congestive heart failure, and type 2 diabetes, who was severely cognitively impaired and required ADL assistance, had multiple unauthorized debits from his resident funds account for online purchases. Items included cologne, boys’ pajamas, slippers, socks, various snack foods, soda, a record player, dementia activity items, televisions, a fidget blanket, and a music set. The resident’s representative had not authorized these purchases, and there was no progress note documentation by the former BOM, AD, or SS. A search of the resident’s room showed that some items were missing and some were found in the activities department. The Administrator verified that the former BOM and former AD used this resident’s funds to purchase these items without authorization. Interviews with former staff clarified how these actions occurred. The former BOM stated that she informed the former AD and former SS when Medicaid residents’ account balances exceeded $2000 and needed to be spent down, and that some items purchased were used by the activities department. She reported that the former AD and former SS would talk with residents about their needs and interests and then order items from the facility’s online retailer account. The former AD stated that he placed online orders as directed by the Administrator and former BOM, based on lists of items they provided that were said to be derived from conversations with residents. Across the affected residents, required authorization from residents or their representatives was not obtained, documentation in the medical record was lacking, and some purchased items were not in the residents’ possession, constituting misappropriation of resident funds and belongings. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that residents be free from misappropriation of property. Despite these policies, the documented practice involved staff initiating and completing purchases using resident funds without the necessary signatures or clear consent, and in some cases items were used by the activities department or not located with the resident. These actions and omissions led to substantiated findings of misappropriation of resident funds for several residents, as documented in the facility’s self-reported incidents and confirmed by the Administrator.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Misappropriation of Controlled Medications by Agency RN During Night Shift
Penalty
Summary
The deficiency involves the facility’s failure to protect several residents from misappropriation of their medications, specifically controlled substances and other drugs. Multiple residents with intact cognition and orders for pain medications, including opioids and gabapentin, were affected. One resident with rheumatoid arthritis, chronic pain, and COPD had an order for scheduled oxycodone; another resident with COPD, diabetes, and morbid obesity had an as-needed oxycodone order; a third resident with schizophrenia and phantom limb pain had an order for gabapentin; a fourth resident with arthritis and muscle wasting also had an order for gabapentin; and a fifth resident with osteomyelitis and rheumatoid arthritis had an as-needed oxycodone order. At the time of later interviews, the cognitively intact residents reported they were unaware of any misappropriation and felt their pain was well managed, but records showed that their medications had been misappropriated. The events leading to the deficiency centered on a night shift during which an agency RN was the only nurse assigned to one side of the building, with an agency LPN assigned to the other side. Pharmacy delivery records showed that oxycodone tablets had been delivered for two residents, but the corresponding Individual Patient Controlled Substance Administration Records for those medications were missing. During the 7:00 p.m. to 7:00 a.m. shift, the agency RN documented wasting oxycodone tablets for two former residents, with cosignature initials that the facility later determined did not match any staff on duty. The next morning, during shift-to-shift controlled substance counts, the agency RN reported that she had dropped all the controlled substance cards and that another nurse had helped her reorganize them. Witness statements from oncoming LPNs described that the agency RN attempted to have them clock her out on the agency app before report, stated that the cards had been dropped and reorganized, and then completed a count that initially appeared correct. Within minutes after the agency RN left, the oncoming LPNs recounted the controlled substances and discovered discrepancies. A full card of oxycodone for one resident and four oxycodone tablets for another resident were missing, along with the associated count sheets. Additional review showed that a card of oxycodone signed into the cart two days earlier was no longer present and not documented as removed, and that some controlled substances were documented as wasted with unrecognizable cosignature initials. Further investigation revealed that two cards of gabapentin for one resident and one card of gabapentin for another resident were also missing. The agency LPN who was alleged to have assisted with reorganizing the cards denied ever going to the other side or wasting medications with the agency RN. Facility staff, including the MDS nurse and DON, confirmed that multiple oxycodone tablets and gabapentin cards for the identified residents were missing and that the documentation of wasting and cosigning did not match any staff who had worked during the relevant shift. The facility’s abuse, neglect, exploitation, or misappropriation policy addressed reporting requirements but did not contain language stating that residents were to remain free from misappropriation, and the misappropriation of medications was determined to have occurred prior to the survey.
Tampering and Possible Diversion of Hospice Residents’ Liquid Morphine
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from tampering with and possible diversion of their prescribed liquid morphine, a controlled substance. Three hospice residents with terminal diagnoses and cognitive impairment had active PRN morphine orders for pain and/or shortness of breath. Record reviews for these residents showed that, over a multi‑month period, they had either no or minimal documented morphine administration despite having orders in place and care plans that included assessing pain and administering pain medication as ordered. Daily pain assessments for all three residents consistently documented pain scores of zero, and the Minimum Data Set assessments reflected no recent use of pain medications for two of the residents and only one PRN dose for the third. The self‑reported incident and pharmacy documentation showed that multiple sealed bottles of morphine, assigned to two of the residents, were found with irregularities in appearance and volume. On one evening, nursing staff observed a morphine bottle with a label that appeared wet and smeared, although the bottle and packaging were dry and the controlled substance count was documented as correct. By the following evening, the same sealed bottle showed a 2–3 mL discrepancy between the amount that should have been present and the amount actually in the bottle, yet the oncoming and off‑going RNs signed the controlled substance count as correct and did not report the discrepancy. Subsequent counts by other nurses identified that the bottle and packaging were wet, the label was smeared, and there remained a 2–3 mL discrepancy between the recorded 15 mL and the 12 mL present in the sealed bottle. Further review revealed another unopened morphine bottle that was wet and contained only 12 mL instead of the full 15 mL, and later a separate bottle was found with a 1 mL discrepancy. The pharmacist’s on‑site review identified single puncture holes on the bottoms of two morphine bottles, confirming tampering. Police took three bottles as evidence and stated they were definitely tampered with, and the incident was described as an ongoing investigation. The facility’s abuse, neglect, and misappropriation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and the tampered morphine bottles were documented as belonging to two of the hospice residents.
Misappropriation of Resident Funds by Housekeeping Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a housekeeper accepted money and financial assistance from the resident over an extended period. The resident, identified as Resident #65, was admitted with multiple medical diagnoses including sepsis, hypertension, type 2 diabetes mellitus, end stage renal disease, anxiety disorder, blindness in the left eye, bipolar disorder, and polyneuropathy. Facility records showed no listed contact person, and the resident was later discharged to an independent living facility. A quarterly MDS and progress notes documented that the resident was cognitively intact, with no evidence of cognitive impairment. Text messages between Resident #65 and Housekeeper #150 showed that the housekeeper discussed personal financial needs, including needing money for rent, car payments, tires, diapers and pull-ups for her children, and other expenses. In these exchanges, the resident repeatedly offered and provided money and use of his debit card to the housekeeper, including specific amounts such as $50, $160, $200, $450, and other sums. The housekeeper at times expressed feeling bad about taking more money and acknowledged that the resident had already given her “way too much,” but continued to accept funds and the use of the resident’s debit card. Messages also showed the housekeeper instructing the resident not to let anyone see him give her money and emphasizing that no one could know they communicated outside of work, indicating efforts to keep the financial relationship hidden from facility staff. Additional text messages documented that the resident gave the housekeeper his debit card to purchase items for him such as beef sticks, underwear, socks, soda, chips, candy, hair clippers, shampoo, toothpaste, and cough drops, while also allowing her to use the card for her own needs, including car payments, hotel stays, and toys and supplies for her children. The communications reflected a personal relationship in which the resident expressed affection and the housekeeper acknowledged that he wanted to help her financially, while she continued to accept money and card access. After the resident’s death, his friend and his daughter reported to the LNHA that a staff member had been taking money from him and having a relationship with him, and the daughter further reported that a nurse at the independent living facility had to stop the housekeeper from entering the resident’s apartment to obtain his debit card after he was hospitalized. Another resident reported knowing that the deceased resident had given his debit card to the housekeeper to buy things and had heard that he paid her bills after discharge. These events and communications formed the basis for the finding that the facility failed to ensure the resident was free from misappropriation of property by staff.
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