F0602

E

Misappropriation and Poor Accountability of Controlled Medications

Independence, Missouri Survey Completed on 12-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of controlled medications and to maintain required accountability documentation for narcotics. Multiple facility policies related to theft and misappropriation of resident property, controlled substances, discarding and destroying medication, and medication administration and documentation were requested by surveyors but not provided. The facility’s own records showed extensive discrepancies between narcotic accountability sheets, pharmacy delivery and dispense logs, and medication administration records (MARs) for several residents receiving opioid analgesics for chronic pain and other pain conditions.

For Resident #1, who had chronic pain and a moderately impaired BIMS score, the POS included multiple PRN and scheduled orders for Percocet and later Norco. Pharmacy records showed repeated deliveries of 30-count packs of Percocet and Norco, each requiring its own accountability sheet. However, the facility could not produce several of these accountability sheets, leaving entire 30-count packs of narcotics unaccounted for. On the available accountability sheet dated 8/26/25, LPN A signed out 22 Percocet tablets between 9/1/25 and 9/5/25, while the MAR documented administration of only 4 tablets during that period, leaving 18 tablets unaccounted for. There was also an incident where LPN A documented that 2 tablets were dropped on the floor without a second staff signature to verify wasting. Subsequent pharmacy dispense logs and MARs for Norco showed additional discrepancies, with 12 to 14 tablets at a time unaccounted for, and a urine test for opioids on Resident #1 returning negative despite consistent sign-outs of opioids by LPN A.

For Resident #6, who was cognitively intact and had pain in the right knee, the POS included PRN and scheduled Percocet orders. Review of the MAR and pharmacy logs showed unaccounted Percocet tablets in multiple time frames, including 1 missing tablet in early October, 1 missing tablet in late November, and 5 missing tablets in December. The resident reported only receiving pain medication at night, never requesting PRN doses during the day, and specifically denied receiving early-morning doses that LPN A had signed out. For Resident #9, who was cognitively intact with chronic pain, the POS included PRN oxycodone and later scheduled Norco. An accountability sheet dated 9/10/25 showed that LPN A removed 30 oxycodone tablets and was the only staff member signing the log, while the MAR documented administration of only 5 tablets, leaving 24 unaccounted for. Additional discrepancies occurred with Norco obtained from both the medication cart and the automatic dispenser, with multiple tablets unaccounted for in October, November, and December.

Interviews with staff and the physician further described patterns leading to the deficiency. The DON in training explained that PRN narcotics were administered from bubble packs on the cart and scheduled narcotics from a Pyxis-style machine, and that narcotic administration required documentation both on the MAR and the narcotic accountability sheet. The physician stated that he changed residents’ PRN oxycodone orders to scheduled hydrocodone because he knew oxycodone was not being administered as it was being signed out and suspected narcotic diversion, noting that undocumented medications could not be proven given. Multiple staff, including a CMT and an LPN, reported missing narcotics, patterns of LPN A being the only person signing out PRN narcotics, residents denying receipt of those medications, and entire cards of narcotics disappearing after shifts worked by LPN A. LPN A, who was the ADON and responsible for monitoring narcotic logs, acknowledged prior investigation for diversion, admitted diverting narcotics from one resident to another on a specific date and having a family member falsely sign as a second nurse on an accountability log, and admitted making mistakes with narcotic accountability while being unable to explain why narcotic administrations were not documented on MARs. The Administrator and regional nurse consultant confirmed that LPN A had been under investigation for diversion under both previous and current ownership, that previous owners did not share investigation results, and that LPN A was later allowed access to narcotics again, during which time narcotics continued to go missing.