F0755

D

Unreconciled Missing Narcotics and Inadequate Controlled Drug Accounting

Kerrville, Texas Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of controlled drugs for two residents. For Resident #1, a female with a history including lumbar vertebra fracture, cellulitis, difficulty walking, and cognitive communication deficit, the care plan included a goal of pain management with opioid medications. Physician orders dated December 1, 2025, included Tramadol 50 mg every four hours PRN, and the December 2025 MAR showed no Tramadol administered on 12/23/25. Review of the resident’s Tramadol 50 mg narcotic blister pack revealed one tablet was punched out but not reconciled with the narcotic count sheet, and an Orders Administration Note authored by RN A on 12/23/25 at 5:53 AM documented that it was unknown whether the resident received the PRN Tramadol on that date.

For Resident #2, a female with diagnoses including pulmonary embolism, urinary tract infection, and cognitive communication deficit, the care plan also included a goal of pain management with PRN Hydrocodone every six hours. Physician orders dated December 1, 2025, reflected Hydrocodone 10-325 mg PRN every six hours for pain. Review of Resident #2’s Hydrocodone 10-325 mg narcotic blister pack showed one tablet punched out that was not reconciled with the narcotic count sheet. An Orders Administration Note dated 12/23/25 at 5:53 AM by RN A similarly reflected that it was unknown whether the resident received the PRN Hydrocodone on that date. The facility’s internal investigation file documented that it was alleged that one Tramadol and one Norco were missing for these two residents and that reconciliation sheets were not completed.

Staff interviews and documentation further described the actions and inactions that led to the discrepancy. A written statement by RN A on 12/23/25 confirmed there were two missing narcotics involving these residents. A written statement by MA B on 12/23/25 indicated that MA B could not remember whether the narcotics were given and admitted to not documenting or reconciling narcotic medications on 12/23/25. The Administrator’s timeline indicated that LVN C reconciled the narcotic count with RN A at the end of her shift, showing that the residents had received PRN narcotics on 12/22/25, but when MA B arrived later and took possession of the medication cart, she did so without reconciling the narcotic count with RN A. Later, during an attempted cart transfer, LVN D refused to accept the cart because two controlled substances for these residents were not accounted for. In a subsequent interview, MA B stated she did not count the narcotic medications because she was overwhelmed and distracted, noticed the missing medications at shift change, and maintained she did not administer the missing doses, while also acknowledging that the narcotic counts had not been reconciled. The facility’s policy on Drug Discrepancies/Diversion of Medications stated that all discrepancies, suspected loss, and/or diversion of medications are to be immediately investigated and reported, underscoring that the missing and unreconciled narcotics constituted a failure to maintain drug records in proper order and to account for all controlled drugs.