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F0602
D

Misappropriation of Resident's Narcotic Pain Medication

Plainwell, Michigan Survey Completed on 09-17-2025

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 facility failed to prevent the misappropriation of a resident's narcotic pain medication, resulting in the theft of controlled substances and the potential for delayed pain treatment. The resident involved had multiple significant medical conditions, including multiple sclerosis, polyneuropathy, heart failure, end stage renal disease, and osteoarthritis, and was prescribed Percocet (oxycodone-acetaminophen) to be administered as needed for pain. On the day in question, the resident was away from the facility for dialysis during the time a dose of Percocet was documented as administered to him. Interviews and record reviews revealed that an agency LPN signed out two doses of PRN pain medication for the resident, one at 2:00 PM and another at 8:00 PM. However, transportation logs and staff interviews confirmed that the resident was not present in the facility at 2:00 PM, making it impossible for him to have received the medication at that time. The resident also reported not receiving the 8:00 PM dose, despite it being documented as given. The LPN in question denied misappropriation but could not provide a satisfactory explanation for the discrepancies in the medication administration records. The facility's internal investigation, including review of narcotic count sheets, medication administration records, and transportation documentation, corroborated that the medication was signed out and documented as administered when the resident was not present. The medication count remained correct, indicating that the medication was removed from the cart but not given to the resident, constituting misappropriation of the resident's property.

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