F0602

D

Misappropriation and Poor Control of Narcotic Medications for Three Residents

Freeport, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of narcotic medications and to accurately document and safeguard controlled drugs. For one resident with multiple serious diagnoses and quadruple amputations, the controlled drug record for oxycodone 5 mg showed a discrepancy between the documented count and the actual pills on hand, with two tablets unaccounted for and no administration entries explaining the reduction. Later, pharmacy records indicated that two full cards (60 tablets) of oxycodone had been delivered, but the resident had no oxycodone available for several days. The MAR showed doses signed out as given on days when the medication was not available, and one nurse acknowledged signing for a dose in error. The resident reported being without his prescribed pain medication for four days, experiencing severe pain rated 10/10, with amputation sites feeling like they were on fire, and stated he was only given Tylenol during this period.

For a second resident, the January MAR documented several administrations of hydromorphone 4 mg by two nurses, but there was no corresponding controlled drug receipt/record/disposition form for reconciliation of these doses. Pharmacy delivery records showed that two cards of hydromorphone 4 mg (60 tablets total) had been delivered in early December, yet the narcotic count sheet for one of the cards was missing. The resident, who was cognitively intact and had multiple complex medical conditions including multiple myeloma and chronic kidney disease, stated he had stopped taking hydromorphone in December and confirmed he did not receive hydromorphone doses in January, despite the MAR entries indicating otherwise.

For a third resident with a stage 4 sacral pressure ulcer and severe pain requiring morphine ER, the controlled drug record for morphine sulfate ER 15 mg showed that on one date a nurse signed out two tablets, noted an increased dose to 30 mg, then marked the entry as an error and crossed out the entire line, leaving the count unchanged. The same nurse then documented a single 15 mg tablet at an earlier time that same day, and the card was later destroyed with 19 tablets remaining. A separate controlled drug sheet for morphine ER 30 mg showed a 30 mg dose signed out that same day. Additionally, pharmacy records showed delivery of 60 tablets of hydrocodone/APAP 5-325 mg for this resident, but the facility could not produce any controlled drug receipt records documenting receipt or destruction of these tablets. The facility’s abuse policy defined abuse, including deprivation of necessary goods or services, but did not define misappropriation of resident property.