F0760

E

Unaccounted Narcotics and Incomplete Documentation for Multiple Residents

Independence, Missouri Survey Completed on 12-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately account for and document controlled narcotic medications for multiple residents, resulting in numerous unaccounted tablets and inconsistent records between narcotic accountability sheets, Medication Administration Records (MARs), and pharmacy delivery/dispense logs. For one resident with chronic pain and moderate cognitive impairment, multiple Percocet and Norco orders were in place over several months. Pharmacy packing slips showed repeated deliveries of 30‑count packs of Percocet and Norco, but several corresponding narcotic accountability sheets were missing and could not be provided. Where accountability sheets were available, the number of tablets signed out did not match the number documented as administered on the MAR, leaving significant quantities of Percocet and Norco unaccounted for. In one instance, an LPN documented that two Percocet tablets were dropped on the floor but there was no second‑staff waste documentation.

For a second resident with right knee pain and intact cognition, Percocet was ordered first as PRN and later as a scheduled bedtime dose. Pharmacy records showed delivery of multiple 30‑count Percocet packs, but at least one accountability sheet was missing. On the available accountability sheet, tablets were signed out on several dates, including entries by the ADON/LPN indicating a tablet was dropped without a destruction log, and documentation that tablets were removed from this resident’s supply to administer to another resident. MAR review showed far fewer administrations than tablets removed on the accountability sheet, resulting in multiple unaccounted Percocet tablets. The resident reported only receiving pain medication at night, never requesting PRN doses during the day, and specifically stated they did not receive early‑morning doses that had been signed out by the LPN.

For a third resident with congestive heart failure and chronic pain, oxycodone and later Norco were ordered, initially as PRN and then as scheduled twice daily. Pharmacy packing slips documented delivery of oxycodone blister packs, but one entire accountability sheet for a 28‑count pack was missing. On another oxycodone accountability sheet, many more tablets were signed out than were documented as administered on the MAR, leaving numerous oxycodone tablets unaccounted for. After the switch to Norco and use of a medication dispensing machine, pharmacy dispense logs showed more Norco tablets removed than were documented as administered on the MAR or reflected on the available accountability sheets, again resulting in unaccounted tablets. This resident stated they did not ask for PRN pain medication very often and did not receive all of the oxycodone that had been signed out on the narcotic logs.

Interviews with staff and leadership confirmed that nurses were responsible for PRN narcotics from the cart and bubble packs, CMTs for scheduled narcotics from the dispensing machine, and that all narcotic administrations were expected to be documented both on the MAR and on narcotic accountability sheets. The ADON/LPN, who was responsible for monitoring narcotic logs and as‑needed narcotics, acknowledged being unsure why logs were missing and narcotics unaccounted for, and was also unsure who was responsible for auditing narcotic logs and administration. The DON in training, CMT, physician, and administrator/regional nurse consultant all stated that if a medication was not documented on the MAR, it could not be proven that it was given, and that narcotic documentation on MARs and accountability logs should match. Despite these expectations, the facility was unable to produce all required accountability sheets and could not reconcile multiple discrepancies between narcotic removals, MAR entries, and pharmacy records for the three residents.

No facility policy for Medication Administration and Documentation was provided when requested, and the pharmacy’s operational manager confirmed that each 30‑count narcotic pack should have its own accountability sheet and that if an accountability sheet cannot be accounted for, neither can the narcotic pills associated with it. Across the three residents, there were repeated patterns of missing accountability sheets, unexplained discrepancies between tablets removed and tablets documented as administered, undocumented wastage, and resident reports that they did not receive some of the narcotics that had been signed out for them. These actions and omissions led to the identified deficiency in ensuring residents were free from significant medication errors related to controlled substance reconciliation and documentation.