Misappropriation of Resident’s Controlled Pain Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a prescribed controlled pain medication and its associated narcotic documentation went missing and could not be accounted for. The resident, who had chronic pain syndrome and moderate cognitive impairment with a BIMS score of 12, had an active order for oxycodone 5 mg by mouth every four hours as needed for pain. According to the resident’s record, the last documented administration of the as-needed oxycodone occurred on the evening of 07/03/2025. When the resident later requested the “little white pill,” the assigned LPN checked the narcotics lock box and found that the oxycodone medication card and the narcotic sheet were no longer present, despite having been there during the previous shift when the medication was last given. The LPN verified in the electronic record that she was the last person to administer the PRN oxycodone and then checked the resident’s chart, where she also could not locate the narcotic sheet. She reported the missing medication and documentation to the charge RN, who in turn notified the Administrator and DON. Staff searched for the oxycodone card and narcotic sheet but were unable to locate either, and the facility’s five-day report documented that an undetermined amount of oxycodone could not be found or accounted for. This sequence of events demonstrated that the resident’s controlled medication was wrongfully unaccounted for, constituting misappropriation of resident property as defined by the facility’s abuse, neglect, mistreatment, and misappropriation policy.
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