Misappropriation of Controlled Narcotics
Summary
The facility failed to ensure residents' rights to be free from misappropriation of controlled narcotics for seven residents. Specifically, the facility did not account for a significant number of narcotic tablets, including Oxycodone and Hydrocodone, for these residents. The missing medications were discovered through a review of pharmacy delivery records, controlled substance count sheets, and controlled drug record sheets. Interviews with staff revealed inconsistencies and lapses in the proper documentation and verification processes for controlled substances. Resident #1 had 48 tablets of Oxycodone 10 mg missing, and the DON could not explain discrepancies in the controlled substance count sheet. Resident #2 had 61 tablets of Oxycodone 5 mg missing, and the controlled drug record sheet for this resident was removed and could not be located. Interviews with staff indicated that proper procedures for witnessing and documenting the removal of controlled substances were not followed. Similar issues were found for Residents #5, #6, #7, #8, and #9, with varying amounts of Hydrocodone and Oxycodone tablets unaccounted for. The facility's failure to properly handle, store, and document controlled medications resulted in Immediate Jeopardy for the affected residents. The DON confirmed that the missing narcotic tablets for these residents could not be accounted for due to missing narcotic sheets and medication cards that were improperly removed from the medication cart. This deficiency highlights significant lapses in the facility's controlled medication management and documentation processes.
Removal Plan
- Resident #6 discharged from the facility. Charges to his insurance was reversed and charged to the facility.
- Resident #1 was assessed for pain, no pain was noted and current residents #1, #5, #8 and #9 were assessed for pain by the DON. No pain was noted.
- Controlled medications were reconciled on every medication cart by the DON.
- The pharmacy was informed of the missing medications for residents #1, #5, #8, and #9. The charges to their insurance for their medications were reversed and charged to the facility.
- The DON and SCC conducted interviews with licensed staff to inquire if they had knowledge of controlled medication unaccounted for or if they had suspicion of anyone working while impaired.
- The DON and SCC began auditing the Controlled Medication delivery logs for Resident #1 to ensure all deliveries were added to carts #1 and #2 on Hall #3.
- The DON and SCC began auditing the Controlled Drug Records for residents that were recently discharged or deceased from Hall #3. An audit of controlled medication logs was conducted for every resident in the facility with an order for a controlled medication to determine if other nurses/residents were involved. This was performed by the DON and SCC. Hall #3 was the only hall identified with controlled medications unaccounted for. Any findings were reported to the legal and regulatory authorities: Health Facilities Commission, TN Regional Office; TN Bureau of Investigation; Police Department, Ombudsman and APS.
- The affected residents with a BIMS of 8 or greater were interviewed by the DON, and all stated they received their pain medications, and all denied pain.
- The affected resident with a BIMS less than 8 was assessed for pain by the DON, there was no complaint or signs of pain.
- Pain assessments were completed for all residents on Hall #3 by the nurse managers to determine if any had uncontrolled pain. There were no residents experiencing uncontrolled pain.
- The nurse managers interviewed residents on Hall #3 with a BIMS equal or greater than 8 to determine if their pain is controlled and as needed (PRN) medications had been administered when requested. All stated their pain is controlled and they receive their PRN medications when requested.
- The DON reviewed documented pain levels for uncontrolled pain. No one had uncontrolled pain levels.
- One nurse was suspended due to reasonable suspicion and remains suspended. This nurse was reported to the Tennessee (TN) Board of Nursing. The TN Bureau of Investigation is continuing the investigation.
- A root cause analysis was conducted. It was determined that the nurse did not follow the process for removing controlled medications; obtaining a witness to verify the removal of controlled medications. The process was changed to prevent the nurses/medication aides from removing completed medication cards or discontinued medication cards. The DON or Unit Managers will remove controlled medications from the medication cart; completed medication cards/sheets and discontinued medication cards/sheets.
- A root cause analysis was conducted. It was determined the excess controlled medication cards/sheets did not need to be on the medication cart. A cabinet with 2 locks was secured in the medication room for overflow-controlled medications and a new form was developed, Controlled Substance Overflow Sheet, to record the addition and removal of controlled medication to that cabinet.
- Education was conducted by the Director of Nursing (DON) and Staff Development Coordinator (SDC) with all staff on the Abuse and Misappropriation Policy. Any staff/agency staff who were not educated will be before working their next shift.
- Education was conducted by the DON and SDC with all licensed staff and Medication Aides on the Controlled Medication Policy and process changes for counting/receiving/removing controlled medication. Any staff/agency staff who were not educated will be educated prior to working their next shift.
- Two nurses will verify the pharmacy delivery manifests for controlled medications in the presence of the driver. Once the quantity has been verified, they will sign the pharmacy delivery manifest. Two nurses will sign the Controlled Drug Record sheet and indicate the total quantity for the prescription (RX) number and the number of medication units, i.e. tablets, on the Controlled Drug Record sheet. Once the quantities are verified the two nurses will add the controlled medications to the medication cart and sign them into the Controlled Substance Record sheet.
- The Unit Managers will audit the pharmacy delivery manifests, daily, to verify controlled medications and Controlled Drug Record Sheets were added to the Controlled Substance Count Sheet and for count accuracy.
- The DON/UM will remove all controlled medications with a witness (empty and discontinued) from the medication cart, reconcile the Controlled Substance Count Sheets and compare the Controlled Substance Count Sheets to the Controlled Drug Records as they are removed from the cart to be secured for destruction. No one will remove controlled medication card/sheets without the DON/UM witnessing. This process, along with the process in #5 above, will prevent the ability to remove a count sheet and medication card without being discovered.
- A secured cabinet with 2 locks was placed in the Four Seasons (hall #2) medication storage room. Overflow of controlled medications will be stored in the secured cabinet. The cabinet has 2 locks with 2 separate keys that are assigned to 2 different licensed nurses (the DON and SDC). The DON and SDC will access the controlled medication cabinet as needed: when multiple cards/sheets are delivered and as the nurses need medications due to running out on the cart. The carts will be checked at the end of the day and before the weekend to ensure the residents will not miss a dose of their controlled medication. The transaction will be recorded on the Controlled Substance Overflow sheet. There will not be a key to this cabinet on any other key ring. In the event the DON or SDC are not in the facility, the DON will designate a Clinical Manager to hold one key.
- The licensed nurses/medication aides were educated by the DON, SDC or UM. Any licensed staff including agency nurses that were not educated will be before their next shift.
- An Ad Hoc QAPI was held via phone, with Corporate Leadership, SCC, Pharmacy President (VP) Strategic Accounts, and the Medical Director to discuss new findings and ongoing investigation.
- An Ad Hoc QAPI was held with Corporate Leaders to discuss audit findings, via phone.
- An Ad HOC QAPI was held with the Medical Director to discuss the event and plan of correction.
- An Ad HOC QAPI was held with the Medical Director, to discuss implementation of a secured overflow cabinet for controlled medications, the process for accessing the cabinet and the recording of adding/removing controlled medications. This new process will be discussed in QAPI meetings to ensure compliance and determine any changes that may be warranted.
- The Clinical Interdisciplinary Team (IDT) will audit every scheduled nurse at shift change for accuracy of the count process daily for two weeks then, weekly times (x) 2 weeks, then monthly x 2 months, then quarterly thereafter.
- The DON/Unit Manager (UM) will audit the medication carts to ensure discontinued/completed controlled medications have been removed from the cart and the Controlled Medication Count Sheet accurately records the removal 5 times per week x 2 weeks then, 3 times per week x 2 weeks then, 2 times monthly x 2 months.
- The DON will conduct random audits of the Pharmacy Delivery Report to ensure the delivered controlled medications were accurately added to the medication carts and Controlled Substance Count Sheets; 5 deliveries per week x 2 weeks then, 3 deliveries per week x 2 weeks then, 3 deliveries per month x 2 months.
- The Quality Assurance (QA) Team will review staff education and QA audits for completion and accuracy. Findings of audits will be reported to the QAPI Committee which includes the Administrator, DON, Unit Managers, SDC, Social Services Director, Maintenance Director, Dietary Manager, Life Enrichment Director, Rehab Manager, and Medical Director. The QAPI meetings will be held weekly for 4 weeks then, 2 times per month for the next 30 days then, monthly thereafter or until the QAPI Committee determines substantial compliance has been achieved. The QAPI Committee reserves the right to modify or extend monitoring times according to outcomes.
- Regional oversite has been in place daily. The Senior (Sr.) Signature State Care Consultant has been in the facility assisting with interviews, education, audits, process changes, attending Ad Hoc QAPI meetings and oversight of compliance with process changes. Regional oversite has occurred onsite or by phone from the Sr. Signature State Care Consultant, the Regional VP of Clinical Operations, or the Regional VP of Operations. The Regional team has collaborated with the facility team on process changes and attended Ad HOC QAPI meetings via phone to discuss audit findings and develop a plan of correction.
Penalty
Resources
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The facility failed to protect resident narcotic medications from misappropriation when an LPN handed over a medication cart’s narcotic keys to an RN without performing required narcotic counts before and after the transfer, and the cart was later found unlocked in the nurses’ station. During the subsequent shift change count, staff discovered multiple missing doses of oxycodone-acetaminophen and hydrocodone-acetaminophen prescribed PRN for pain to four residents with conditions including dementia, COPD, dysphagia, and diabetic neuropathy. Review of individual controlled drug logs showed corrected balances to account for the missing tablets, confirming that controlled substances were unaccounted for during the period of unsecured cart access and improper key control.
A resident with severe cognitive impairment and dementia had facility-managed trust funds used to purchase three Meta virtual reality headsets via Amazon. The corresponding debit was recorded in the trust account, but the devices were later found stored, largely unopened, in the activities room, with the activities director unaware of their ownership or use and unable to operate them. The resident’s representative was not informed of the purchase and believed the resident could not use such devices, while the NHA stated the items were bought as part of a Medicaid spend-down for the resident and possibly friends.
The facility failed to prevent misappropriation of resident property when an LPN removed multiple residents' medications from the facility without consent, despite a policy prohibiting such conduct and defining drug diversion as misappropriation. An anonymous caller reported finding a purse on the roadside containing a bag with multiple residents' medications, along with employment-related documents bearing the LPN's name. Review of MARs showed that all of the involved medications for eleven residents had been signed out by this LPN on the corresponding shifts, and the facility’s investigation substantiated misappropriation of property.
A resident with impaired memory and no capacity for medical decision-making had their eyeglasses lost, and the facility did not replace them or reimburse the cost in a timely manner. The RP reported the missing glasses, and the SSA stated that a theft and loss form was supposedly completed, but neither the SSA nor the DON could locate this documentation. The SSA could not specify when the glasses were lost, only that it occurred over several months, and later records showed the resident declined new glasses despite lacking decision-making capacity, with no notification to the RP. The facility’s own theft and loss policy requiring prompt investigation, documentation, and notification of the resident or representative was not followed.
A resident’s controlled medication, Lorazepam 0.5 mg, went missing from a medication cart, with the narcotic record showing 19 tablets remaining but the bubble pack unable to be located during a shift-change narcotic count by two RNs. The medication had been verified as present and correctly counted by two RNs on the prior shift, and a torn label from the missing Lorazepam bubble pack was later found in the bedside table of an empty room, but the tablets were not recovered. As a result, the resident missed two scheduled doses, and the incident constituted misappropriation of the resident’s property in violation of facility policies on controlled substances, resident rights, and investigation of theft/misappropriation.
Multiple residents experienced misappropriation and tampering of their prescribed narcotic medications when several bottles of liquid morphine, used for pain, shortness of breath, and air hunger, were found to be clear and watery instead of the usual pink and viscous solution after prior counts and administrations had confirmed the correct appearance. In a separate event, an entire card of hydrocodone-acetaminophen (Norco) ordered three times daily for a hospice resident with chronic back pain, heart failure, and dysphagia went missing and was never located, despite narcotic counts confirming its prior presence. Facility documentation and staff interviews show that these medications were altered or disappeared between routine narcotic counts, and the individual responsible was not identified, resulting in misappropriation of residents’ medications.
Failure to Secure Narcotic Medications and Maintain Key Control
Penalty
Summary
The deficiency involves the facility’s failure to protect resident medications from misappropriation on one of four medication carts, resulting in missing controlled substances for four residents. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent. On a specific date, during the 7:00 PM shift change narcotic count, staff identified that multiple doses of Percocet and Norco (hydrocodone-acetaminophen) were missing from the narcotic box on a single medication cart. Prior to this discovery, the assigned LPN had confirmed that the narcotic count was correct earlier in the day. The events leading to the deficiency included the LPN giving her medication cart narcotic keys to an RN while she left the area to perform a urine specimen collection. The LPN did not complete a narcotic count before or after transferring the keys, which was not in accordance with facility expectations for key control and chain of custody. When the LPN returned, she observed the medication cart in the nurses’ station and unlocked. The RN later confirmed that she had moved the cart into the nurses’ station but denied administering any medications during the time she had possession of the keys. During the subsequent 7:00 PM narcotic count, discrepancies were identified, and a search of the cart and nurses’ station did not locate the missing medications. Record review showed that four residents’ controlled medication logs required corrections to reflect missing tablets. One resident with dementia had an order for oxycodone-acetaminophen 5-325 mg every 12 hours as needed for pain; the narcotic log initially showed a remaining balance of 20 tablets after a documented administration, but was later corrected to 16 tablets to account for four missing tablets. A second resident with COPD had an order for oxycodone-acetaminophen 10-325 mg every eight hours as needed; the log was corrected from a remaining balance of five tablets to four, indicating one missing tablet. A third resident with dysphagia had an order for hydrocodone-acetaminophen 5-325 mg every 24 hours as needed; the log showed two tablets on hand after the resident returned from pass with no administrations documented, and was later corrected to zero, indicating two missing tablets. A fourth resident with type 2 diabetes mellitus with diabetic neuropathy had an order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed; the log was corrected from a remaining balance of eight tablets to seven, indicating one missing tablet. These discrepancies, combined with the unsecured cart and improper key transfer without counts, led to the determination that resident medications were not protected from misappropriation.
Misappropriation of Resident Trust Funds for Unused Virtual Reality Devices
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when items were purchased with the resident’s trust account funds and not used for the resident’s benefit. The resident had severe cognitive impairment, with a BIMS score of 3/15 and diagnoses including dementia, non‑traumatic brain dysfunction, and Meniere’s disease, and the facility managed the resident’s funds through a trust account. Documentation showed that an Amazon order was placed for this resident that included three Meta virtual reality headsets at $399.99 each, and the resident’s trust account transaction history reflected a corresponding debit of $1,878.78 for Amazon purchases. Attempts to interview the resident were unsuccessful due to cognitive debilities. Surveyor observation found three Meta virtual reality headsets in their original boxes, one opened, stored in the activities storage room near the main dining room. The activities director stated she did not know who the devices belonged to, that they had been stored in the closet since February of the prior year, that the devices required internet access, and that she did not know how to use them. The resident’s responsible party reported having no knowledge of the Meta purchase and did not believe the resident would have been capable of operating the devices. The NHA stated that the resident was obligated to spend down the trust account as a Medicaid requirement and that three Meta virtual reality headsets were ordered for the resident and possibly some friends to use.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from misappropriation of property when an LPN removed multiple resident medications from the facility without consent. Facility policy on identifying exploitation, theft, and misappropriation of resident property, dated 9/1/25, defines misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent, and specifically lists drug diversion as an example. Despite this policy, an anonymous male caller notified the center supervisor that he had found a purse on the side of the road containing multiple medication cards for several residents of the facility. When the DON and Administrator went to the police station, they were shown a pink bag containing multiple medications, a Tuberculin employment skin testing record, and an orientation sheet, both bearing the name of LPN Employee E1. The bag contained eleven residents' medications in individual dispense bags, with no controlled substances identified. The medication dates and assignment areas matched LPN E1's work assignments on the relevant days and shifts, and the MARs for all residents on those assignments showed that all medications were signed out by this LPN. The facility’s investigation substantiated misappropriation of property for 11 of 49 residents (R1, R2, R12, R13, R14, R15, R16, R17, R18, R19, and R20). During an interview, the Nursing Home Administrator and Interim DON confirmed that the facility failed to ensure residents were free from misappropriation of property.
Failure to Replace Lost Eyeglasses and Notify Resident Representative
Penalty
Summary
The facility failed to protect a resident’s personal belongings when the resident’s eyeglasses were lost and not replaced in a timely manner. The resident was admitted in late 2025 with a diagnosis that included a brain disease impairing memory, and an Order Summary Report dated 9/17/25 documented that the resident did not have capacity to make medical decisions. The resident’s responsible party (RP) reported that the facility had lost the resident’s glasses and had neither replaced them nor reimbursed the cost of replacement. The Social Service Assistant (SSA) stated that the usual process for a lost item was to complete a theft and loss form, communicate with family, and have the facility pay for the lost item if it was not located, with a copy of the form kept in the social services office. During interviews and record review, the SSA recalled that the RP had reported the glasses missing and that the facility had met with the RP to discuss the loss, and she stated that a theft and loss form had been completed. However, the SSA and DON were unable to locate any theft and loss form for the lost glasses, and the SSA could not identify the exact date the glasses were lost, only that it occurred sometime between September and December 2025. An eye exam form dated 1/22/26 showed the resident declined new eyeglasses after the exam, but the SSA confirmed the resident lacked capacity to make medical decisions and that the RP should have been notified, which did not occur. The SSA confirmed that nothing further had been done to replace the glasses and acknowledged that glasses were important to help residents see. The facility’s policy on investigating incidents of theft and loss required prompt and thorough investigation of theft or misappropriation, prompt response to complaints, and notification of the resident and/or representative of investigation results and corrective action, which was not demonstrated in this case.
Misappropriation of Resident’s Controlled Lorazepam and Resulting Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a controlled medication, Lorazepam 0.5 mg, went missing from the medication cart, resulting in missed doses. During a narcotic count at shift change on 11/30/25, RN A and the night shift nurse (RN B) were unable to locate the resident’s Lorazepam bubble pack, which should have contained 19 tablets according to the narcotic record. RN A reported that three medication carts and 48 resident rooms were checked, but the medication could not be found, and confirmed that the resident missed two scheduled doses on 11/30/25 and 12/1/25. The facility’s controlled substances policy required controlled medications to be reconciled upon receipt, administration, disposition, and at the end of each shift, with incoming and outgoing nurses jointly determining the count. Interviews and record review established that the Lorazepam had been present and accounted for at the end of the prior shift. RN B stated that at the start of her night shift on 11/29/25 all narcotics were accounted for, and at the end of her shift RN A discovered the Lorazepam bubble pack was missing, despite the narcotic record book indicating 19 tablets remained. RN C, who worked the evening shift before RN B, confirmed that all narcotics, including the resident’s Lorazepam, were accounted for during the count with RN B, and both signed the narcotic book indicating no discrepancies. The MDS Coordinator later found a torn medication label from the missing Lorazepam bubble pack in the bottom drawer of a bedside table in an empty room, but the 19 tablets were not recovered. The DON confirmed that the medication had been accounted for on 11/29/25, was missing during RN B’s night shift, and that the torn label matched the missing Lorazepam, constituting misappropriation of the resident’s property in violation of the facility’s resident rights and misappropriation policies.
Misappropriation and Tampering of Residents’ Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their prescribed narcotic medications. On one occasion, a nurse identified that several bottles of liquid morphine intended for residents were discolored and had a different consistency than usual. Facility documentation and staff interviews state that morphine in seven bottles, associated with four residents, appeared clear and watery instead of the usual pink and more viscous solution. Narcotic counts conducted around shift changes did not initially show discrepancies, and staff verified that the morphine had been the correct pink color when administered on prior shifts, indicating that the contents were switched to a clear liquid sometime after the last accurate count. The affected residents were receiving morphine for significant pain and symptom management. One resident had an order for concentrated morphine sulfate 20 mg/mL, 0.25 mL by mouth every hour as needed for pain or shortness of breath and had a diagnosis of polyneuropathy. Another resident was ordered morphine sulfate 10 mg/5 mL, 0.25 mL every two hours as needed for pain or shortness of breath, with diagnoses including partial intestinal obstruction and palliative care. A third resident had an order for morphine sulfate 20 mg/5 mL, 0.25 mL every two hours as needed for severe pain or air hunger and a diagnosis of compression fracture of the thoracic vertebra. A fourth resident was ordered concentrated morphine sulfate 100 mg/5 mL, 0.25 mL every hour as needed for pain, with diagnoses including diabetic neuropathy and a history of healed traumatic fracture. Staff interviews and facility reports confirm that the morphine for these residents had been altered and that the liquid in the bottles did not match the expected color and viscosity. A separate incident involved misappropriation of a different resident’s hydrocodone-acetaminophen (Norco). This resident, who had chronic back pain, was on hospice for heart failure and dysphagia and had an order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth three times daily for pain, not to exceed 4 g/day. Facility documentation and staff interviews state that an entire card of 60 hydrocodone tablets for this resident went missing over a period of days. Narcotic counts before and after the disappearance confirmed that the card had been present during one count and was no longer present at a subsequent count, and the card was never located. In both the morphine and hydrocodone incidents, the facility’s own reports and staff statements confirm that residents’ prescribed narcotic medications were either altered or missing and that the responsible individual was not identified, resulting in misappropriation of residents’ personal property in the form of their medications.
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