F0755

D

Failure to Reconcile and Safeguard Controlled Medications Resulting in Narcotic Diversion

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own protocols for reconciliation and control of narcotic medications, resulting in undetected diversion of controlled substances for two residents. For one resident with acute osteomyelitis of the right ankle and foot, infection and inflammatory reaction due to an internal left hip prosthesis, and left hip pain, the admission evaluation and care plan documented high‑risk medications and pain management needs. A physician order was in place for oxycodone 5 mg by mouth every 6 hours as needed for pain rated 4–10, along with an order for pain evaluation using a 1–10 pain scale every shift. However, this oxycodone order was not transcribed onto the February MAR. A narcotic card audit conducted by the DON showed that 58 oxycodone 5 mg tablets had been dispensed for this resident, and the audit documentation for this medication was highlighted and incomplete, with no indication that the medication was in the cart or scanned.

For another resident admitted with atherosclerotic heart disease, muscle weakness, and acute hematogenous osteomyelitis of the right ankle and foot, there was a physician order for oxycodone‑acetaminophen 10‑325 mg, one tablet by mouth every 6 hours as needed for pain level 1–10. The care plan documented that the resident was on an opiate and required medications to be administered as ordered, and there was also an order for pain evaluation using a 1–10 pain scale every shift. The MAR for February showed that the oxycodone‑acetaminophen order was transcribed and documented as administered on two dates. Provider notes indicated that the resident complained of leg pain and that pain control was adequate, with a plan to continue the current pain regimen. Despite this, the narcotic card audit revealed that 20 tablets of oxycodone‑acetaminophen 10‑325 mg had been dispensed, but the audit entry was highlighted, lacked a check mark, and was marked as not applicable.

The facility’s internal investigation documented that two nurses on consecutive shifts completed medication reconciliation for the second resident’s oxycodone‑acetaminophen and that both the bubble pack and narcotic count sheet were present at that time. The following day, a registry RN accepted the cart from the night shift nurse and identified that the narcotics and count sheet were present, but when that RN later passed the cart to the next nurse, the narcotic sheet and bubble pack for the oxycodone‑acetaminophen were no longer present. The investigation stated that the registry RN concealed this information and did not properly report it during handoff. Camera footage reviewed by the facility showed the registry RN entering the medication room, pretending to place medications into a cabinet, and instead stuffing medication bubble packs down the front of her scrubs. During an audit of all residents on controlled medications, the facility determined that this RN had removed the first resident’s oxycodone 5 mg, totaling 58 tablets, which were from a discontinued order set for destruction. The facility substantiated misappropriation of medications based on this evidence. Interviews with nursing staff and review of the facility’s controlled substances policy confirmed that the established process required two‑nurse narcotic counts each shift, reconciliation of declining inventory records with MARs and access records, and immediate reporting and investigation of discrepancies, but these controls did not prevent or timely detect the diversion involving these two residents’ narcotics.

Additional staff interviews further described the expected practices that were not effectively implemented in this incident. An RN stated that it was never acceptable to use one resident’s controlled medication for another and that two nurses were to conduct narcotic counts at shift change, with any discrepancies immediately reported to the DON. An LPN explained that the oncoming nurse was to count all controlled medication cards, bottles, and syringes for every resident, with two nurses verifying that all medications were accounted for, and that any discrepancy would prompt review of the previous three shifts and notification of the DON. The DON described the reconciliation process in which the oncoming and outgoing nurses compare the narcotic sheet with the physical bubble packs, first by card count and then by pill count, and notify her of any mismatch for investigation and possible notification of the administrator and consultant pharmacy. Despite these written policies and described procedures, the documented diversion of oxycodone and oxycodone‑acetaminophen for the two residents occurred, and the missing narcotics and associated documentation were not identified and addressed at the time of shift‑to‑shift reconciliation.