F0602

D

Failure to Safeguard and Accurately Account for Controlled Pain Medication

Indianapolis, Indiana Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident’s controlled medications from diversion and to maintain accurate narcotic accountability. A resident with diagnoses including cervical radiculopathy, fibromyalgia, carpal tunnel syndrome, and lumbar disc degeneration had a physician’s order for hydrocodone-acetaminophen (Norco) 5-325 mg, one tablet by mouth every six hours for pain. A pain assessment documented that the resident verbalized severe pain. A pharmacy packing slip showed that a nurse signed for receipt of four cards of 30 Norco tablets (total 120 tablets) for this resident. The resident was later found unresponsive at 6:00 a.m., CPR was initiated but unsuccessful, and the resident was pronounced dead at 6:15 a.m.

Subsequently, two full cards of the resident’s Norco, totaling 60 tablets, were discovered missing from the medication cart. A nurse reported that she had last seen the resident’s Norco cards at the end of her shift prior to the discovery, and when she returned to work she noted that two cards were missing even though the narcotic count matched the narcotic count sheets. Staff interviews revealed that the narcotic count sheet for this resident was altered: a page was missing from the narcotic count book, the pages of which were numbered sequentially, and a new narcotic count sheet had been started. The night-shift nurse had only the new narcotic sheet to reference and was unaware that additional cards should have been present. The nurse suspected of involvement admitted starting a new narcotic count sheet but denied removing the original page or taking the missing narcotics.

The facility’s records further showed that a narcotic count sheet for the resident’s Norco was still being signed as having 45 tablets nineteen days after the resident’s death, indicating that the medication remained on the cart well beyond the time of death. Staff interviews indicated that, per facility practice and policy, the DON was responsible for destruction of narcotic medications after a resident’s discharge or death, and that narcotics were not to be destroyed by hallway nurses. There was also a delay in removing and destroying the resident’s narcotics from the cart. Review of shift change/controlled substance inventory tracker sheets from all six medication carts showed that two nurses had not consistently signed as required when narcotic cards and count sheets were added or removed, contrary to facility policy that required two-nurse verification of controlled drug counts, cards, and count sheets at each shift change. These actions and inactions resulted in 60 missing Norco tablets and demonstrated a failure to safeguard the resident’s narcotic medications from diversion and to maintain proper chain of custody and documentation.