Failure to Report Attempted Narcotic Diversion to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to notify law enforcement and the state surveying agency of an attempted diversion of narcotic medications involving two residents. A registered nurse (V3) reported that on 08/09/25 he left two bingo cards of Norco, one for resident R7 and one for resident R8, on top of a cabinet in the medication room while he went on break. When he returned, the medications were no longer where he had placed them. V3 stated that only he and another RN (V4) had keys to the medication room. After searching the medication room, V3 found both bingo cards containing Norco inside V4’s unzipped personal shoulder bag. V3 notified the DON (V2), who, along with the Administrator (V1), came to the unit. V2 stated she removed the medications from V4’s bag and that V4 admitted placing the narcotics in her bag and reported she was addicted to drugs and had recently been in rehab. V1 confirmed that the narcotic medications found in V4’s personal bag belonged to R7 and R8 and stated that the police were not called because the medications had not left the facility, the narcotic count was accurate, and no residents missed any medications. V1 also stated that V4 was not reported to the state licensing agency or the state surveying agency for the same reasons. R7 had diagnoses including major depressive disorder, bipolar disorder, anxiety, osteoarthritis, cervicalgia, and a left-hand contracture, and had discontinued orders for Norco 10-325 mg as needed for pain with start dates in July and August 2025. R8 had diagnoses including acquired absence of the right leg below the knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes, and had an order for Norco 5-325 mg every 12 hours as needed for severe pain for five days in August 2025. The facility’s policy on discrepancies, loss, and/or diversion of medications required that all suspected loss or diversion be immediately investigated and that appropriate agencies required by state regulation be notified, but law enforcement and the state surveying agency were not notified in this incident.
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