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F0602
D

Misappropriation of Controlled Pain Medication Due to Improper Narcotic Counting

Pendleton, Oregon Survey Completed on 08-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a card of oxycodone, a Schedule II controlled pain medication prescribed to a cognitively intact resident with an abdominal wall infection, was found missing during a routine narcotic count. The investigation revealed that certified medication aides (CMAs) and nurses on the night shift were not properly counting the narcotic drawer, which led to the loss of the resident's medication. The missing medication was not found, and the facility determined that misappropriation of the resident's property had occurred. Interviews confirmed that the resident was unaware of any missed doses and had not experienced any interruption in receiving needed pain medication. Staff involved in the narcotic count reported the missing card and acknowledged that the medication was likely thrown away by mistake due to improper counting procedures. The incident was substantiated as misappropriation of resident property following the facility's internal investigation.

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