F0755

D

Failure to Properly Witness and Reconcile Wasted Narcotic Medications

Asheville, North Carolina Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain effective systems for accurate reconciliation and proper wasting of narcotic medications, specifically oxycodone, for two residents. One resident had a standing order for oxycodone 10 mg three times daily for pain, and review of the narcotic record showed that an agency nurse (Nurse #1) signed out oxycodone doses on a specific evening. The same record showed that another agency nurse (Nurse #2) signed as a witness to the disposal of an oxycodone 10 mg tablet at an illegible time. A second resident had an order for oxycodone 10 mg every three hours as needed for pain, and the narcotic record indicated that Nurse #1 signed out oxycodone doses for this resident on the same evening, with Nurse #2 again signing as a witness to the disposal of an oxycodone 10 mg tablet at an illegible time.

The facility became aware of a possible misappropriation of residents’ property when a staff nurse (Nurse #3) reported concern to the DON that as-needed narcotics were being signed out for a resident who usually did not request pain medication, and that some as-needed oxycodone was missing for one of the residents. Nurse #3 also noted that the medications were not signed as administered on the MAR and that the resident denied taking the pain medication. Subsequent review of the narcotic sign-out sheets showed that Nurse #2 had signed as a witness to Nurse #1’s disposal of narcotics for both residents. In an email to the DON, Nurse #2 admitted signing the narcotic sheets as a waste witness at Nurse #1’s request without visually observing the disposal of the medications, contrary to the facility’s standard practice that nurses visually witness narcotic waste before signing as a witness.