F0610

E

Failure to Fully Investigate Misappropriation of Controlled Medications for Multiple Residents

Pittsburgh, Pennsylvania Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to implement its abuse, neglect, and exploitation policy to fully investigate potential misappropriation of resident property, specifically controlled medications, for multiple residents. The policy required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, preserving potential evidence, investigating all types of alleged violations, interviewing all involved persons, and providing complete documentation. An incident was identified in which one tablet of lorazepam 0.5 mg prescribed to a resident with peripheral vascular disease and dementia (BIMS score 1, on scheduled lorazepam) and one tablet of clonazepam 1 mg prescribed to a resident with schizophrenia and anxiety (BIMS score 15, on scheduled clonazepam) were found missing during a narcotic count. The missing medications were stored in a locked medication cart on the sixth floor, and the discrepancy was discovered during routine narcotic count reconciliation while an LPN was in charge of the cart.

Following discovery of the two missing controlled substances, the facility’s investigation focused on the LPN assigned to the cart and the nurse who handed off the cart, including obtaining statements about the narcotic count at shift change and the LPN’s report of not having reading glasses and being unaware of an incorrect count. Narcotic count sheets and the MAR were reviewed for the two residents whose medications were missing, and statements were obtained from the involved LPNs. During the course of this focused inquiry, a RN who served as the Assistant DON was later found to be in possession of an extra set of medication cart keys and had been working in the facility during the time frame of the discrepancy. However, the investigation documentation provided did not show that the facility broadened its review beyond the two initially identified missing doses to determine whether misappropriation extended to other residents.

When additional narcotic sign-out sheets were reviewed with the DON, numerous discrepancies were identified for twelve other residents, including extra doses of hydromorphone, tramadol, oxycodone, oxycodone/acetaminophen, alprazolam, and other controlled medications signed out on paper but not documented in the electronic MAR, illegible entries, doses recorded after orders had been discontinued, and multiple doses signed out in time frames inconsistent with the physician’s orders. These discrepancies involved residents with various pain and anxiety medication regimens and included instances where orders were no longer active or where extra or wasted doses were recorded without corresponding MAR documentation. The DON confirmed that the facility’s investigation into misappropriation did not include audits of other residents’ medication records, narcotic sign-out sheets, or resident interviews to determine whether misappropriation involved additional residents. The Nursing Home Administrator also confirmed that the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services and 28 Pa. Code 201.29(j) Resident rights.