F0609

E

Failure to Report Suspected Misappropriation of Controlled Medications

Pittsburgh, Pennsylvania Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report suspected misappropriation of resident property, specifically controlled substances and other medications, for 12 of 14 residents as required by its Abuse, Neglect, & Exploitation policy and state regulations. The facility’s policy dated 2/14/25 required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, depending on whether abuse or serious bodily injury was involved. Despite this, documentation submitted to the State Survey Agency did not include reports of possible misappropriation for the affected residents, and the Nursing Home Administrator later confirmed that the facility failed to implement its policies and procedures for reporting possible misappropriation of resident property.

Surveyors’ review of narcotic sign-out sheets and the electronic MARs for multiple residents showed numerous additional doses of controlled and other medications signed out on paper but not documented in the electronic MAR. For one resident, extra doses of hydromorphone were recorded on paper on several dates without corresponding MAR entries. Other residents had undocumented paper sign-outs for Tramadol, oxycodone, oxycodone/acetaminophen, and alprazolam, including instances where multiple doses were signed out in a short time frame, illegible entries, and doses signed out after the physician’s order had been discontinued. One resident’s record showed three doses signed out between 12:20 a.m. and 5:00 a.m. when only one dose was scheduled, and another resident’s record showed wasted doses and multiple undocumented administrations.

Further review showed that for one resident, a narcotic inventory discrepancy was identified, with 4½ tablets of oxycodone 5 mg unaccounted for between two documented counts, and no medication administration recorded during that interval. Activity records indicated that an RN accessed the narcotic drawer shortly before the discrepancy was noted. Despite these discrepancies and the facility’s own policy requiring prompt reporting of alleged violations, the facility did not report these possible misappropriations for 12 residents to the State Survey Agency or other required authorities, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(5) and 201.29(j).