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F0602
D

Misappropriation of Resident Pain Medication by LPN

Lynchburg, Virginia Survey Completed on 09-13-2025

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 an LPN misappropriated a resident's prescribed oxycodone pain medication without the resident's consent. The resident, who had a history of pain, osteoarthritis, and low back pain, was admitted with a care plan that included scheduled and as-needed pain medications. The resident had moderate cognitive impairment, as indicated by a BIMS score of 10, and was dependent on staff for medication administration. On the date of the incident, the LPN removed three tablets of oxycodone from the narcotic control count log, but the resident declined the medication, and the medication was not administered as prescribed. The incident came to light when the resident's family reported that the resident had not received the as-needed pain medication as requested. Upon investigation, it was found that the LPN had signed out the medication as given, but the resident denied receiving it. The LPN informed the resident that the oxycodone was not available and instead provided other medications, specifically hydroxyzine and Tylenol, while falsely stating that the controlled pain medication was unavailable. The resident documented this by sending a picture of the pills to a family member, prompting further inquiry. Further review of the narcotic count log and interviews with the resident and staff confirmed that the LPN had diverted the medication. The LPN was unable to provide a valid explanation for the missing medication and failed to comply with a request for a valid urine drug screen. The facility substantiated the misappropriation of the resident's property based on resident statements and the narcotic count review. No negative outcomes were identified for the resident as a result of the diversion.

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