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F0602
E

Nurse Misappropriation of Resident Narcotics

Amarillo, Texas Survey Completed on 06-03-2025

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 nurse (LVN A) was observed and recorded on video taking narcotic medications from the medication cart, removing pills from multiple residents' bubble packs, and consuming them herself. The video evidence showed LVN A accessing the narcotic drawer, popping out approximately 14 pills from various residents' medications, and ingesting them. On another occasion, she was seen placing medications in her pocket and later consuming them. The identities of the specific residents whose medications were taken could not be determined from the video, but the actions were confirmed by direct observation and interviews. Resident interviews revealed that one resident, who was fully alert and oriented, reported not receiving scheduled hydrocodone doses from LVN A, despite the nurse documenting administration. This resident was able to accurately recall his medication regimen and noted improvement after LVN A's departure. Other residents did not report missing medications, but one mentioned a nurse offering pain medication that was not requested. Medication Administration Records (MARs) for the reviewed period did not show discrepancies, but staff interviews indicated frequent unexplained medication wastage and increased frequency of narcotic orders. Staff interviews and review of narcotic log books revealed that LVN A was the sole signatory for multiple instances of wasted, dropped, or refused narcotics, with no required second signature. Other nurses reported suspicions due to increased medication usage and missing doses, which were reported to the Director of Nursing. The facility administrator confirmed that the issue came to light after a resident complained of pain and a review of video footage was conducted. A police report was filed, and a drug test of LVN A was positive for multiple controlled substances.

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