F0602

E

Misappropriation of Resident Medications and Funds from Secured Medication Cart

Pittsburgh, Pennsylvania Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of property, including controlled medications and personal funds, for three residents. Facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. Resident R1, with diagnoses including peripheral vascular disease and dementia and a BIMS score of 1 (severe cognitive impairment), had an order for lorazepam 0.5 mg three times daily. Resident R2, with schizophrenia and an anxiety disorder and a BIMS score of 15 (cognitively intact), had an order for clonazepam 1 mg twice daily. During a routine narcotic count reconciliation on the 6th floor medication cart, one tablet of lorazepam belonging to Resident R1 and one tablet of clonazepam belonging to Resident R2 were found to be missing/unaccounted for. The medications had been stored in a secured, locked medication cart assigned to LPN Employee E1 at the time the discrepancy was discovered.

Statements obtained during the investigation revealed conflicting accounts regarding the narcotic count and access to the cart. In an initial verbal statement, LPN Employee E1 reported that the count was wrong that morning when she counted with another LPN and stated she did not have her reading glasses and did not know the count was wrong. In a later written statement, she corrected the name of the nurse she counted with but maintained that the Ativan and Klonopin counts were not correct. However, LPN Employee E2 stated that when she counted the narcotic drawer with LPN Employee E1 at shift change, all counts matched the records and no discrepancies were noted or questioned. Facility documentation indicated that both nurses reported the narcotic count was accurate at the time of shift change, and that the discrepancy was later identified through review of narcotic count sheets and MAR documentation. During the course of the investigation, RN Employee E3, the Assistant Director of Nursing, was found to be in possession of an extra set of medication cart keys and was working in the facility during the timeframe of the discrepancy, indicating that more than one staff member had access to the locked narcotic drawers.

The deficiency also involved misappropriation concerns related to Resident R3’s personal property. Resident R3, with cirrhosis of the liver, end stage renal disease, and a BIMS score of 9 (moderate cognitive impairment), had personal items including a wallet, multiple credit/debit and insurance cards, state ID, and $145 in cash stored in a locked narcotic drawer of the 6th floor medication cart. Staff statements conflicted regarding awareness and handling of this property. One LPN stated that on the morning of December 27, while counting off the cart, there was a stack of cards with rubber bands around it that were said to belong to the resident, and that money was never seen or mentioned and therefore never counted. Another LPN reported last seeing the resident’s money in a clear plastic bag in the narcotic drawer on the morning of December 26, noting a visible hundred-dollar bill, and later noticing that the money was no longer visible when counting the drawer the night of December 27, prompting notification of the acting supervisor. A third LPN stated that on December 27, she specifically informed another nurse that the resident had a wallet, a stack of different credit cards, and $145 in cash in a plastic bag labeled with the resident’s name in the narcotic box, and that she picked up and showed the bundle to ensure the other nurse knew it was there. Facility documentation indicated that the resident’s credit/debit cards, ID, insurance cards, and $145 in cash were being stored in the locked drawer over the weekend to be taken to the business office, and that on December 28 the money was reported missing while the cart was under the control of LPN Employee E1, with concern for loss or possible misappropriation of resident property. The facility’s investigation report later noted that, because more than one nurse had access to the locked narcotic drawer during the relevant timeframe, the investigation into the missing funds was inconclusive and could not be substantiated or unsubstantiated.