F0602

D

Misappropriation and Poor Control of Hydrocodone-Acetaminophen for Two Hospice Residents

Winston-salem, North Carolina Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of their prescribed narcotic medication, Hydrocodone-Acetaminophen, for two hospice residents receiving pain management. One resident with Alzheimer’s disease was started on Hydrocodone-Acetaminophen as needed for left hip pain after an after-hours hospice nurse obtained a 30-tablet supply from a local pharmacy. The local pharmacy confirmed dispensing 30 tablets, and the resident’s MAR showed three doses administered over three days, leaving 27 tablets unaccounted for in that container. The facility’s DON reported that the medication monitoring/control record for this initial supply could not be located. Later, the facility pharmacy delivered an additional 30 tablets for the same resident, signed for by Nurse #1, but the facility again could not locate the corresponding medication monitoring/control record. A further 13 tablets were dispensed on a separate date, and only two doses were documented as administered in October, with no other administrations recorded.

Staff interviews revealed inconsistent accounts and missing documentation related to the narcotic counts and the whereabouts of the Hydrocodone-Acetaminophen for this resident. Med Aide #1 stated that when she assumed the cart from Nurse #1, she saw 25 tablets in the local-pharmacy container and 30 tablets on a medication card for the resident, but during the narcotic count with Nurse #1 the following morning, the Hydrocodone-Acetaminophen for this resident was missing. She initially assumed the medication had been discontinued and did not question Nurse #1, later discovering the order was still active and then notifying the supervising nurse and DON. The DON’s written statement and subsequent interview contained conflicting dates about when she was notified of the missing narcotic, and she reported that all documentation of the facility’s investigation was lost or misplaced. Hospice staff from the resident’s hospice provider confirmed that the Hydrocodone-Acetaminophen belonged to the resident, not hospice, and that they were informed by the facility of a diversion involving 30 tablets on a medication card and an unknown quantity from the local pharmacy.

The second resident, who had cerebrovascular disease and was on hospice services, had an order for Hydrocodone-Acetaminophen every eight hours for pain. The facility pharmacy dispensed 43 tablets (30 on one card and 13 on another), signed for by Nurse #1, and the quantity should have lasted until a later date. The facility could not locate the medication monitoring/control record for the 30-tablet card, though the record for the 13-tablet card showed the resident ran out of medication on a specific date, with the last dose given at 2:00 AM. The MAR documented scheduled dosing three times daily and noted one missed dose with a comment that the facility was awaiting pharmacy. Hospice Nurse #2 received an after-hours call that the resident had run out of Hydrocodone-Acetaminophen and, after reviewing orders and dispensing records, determined the resident should not have run out until a much later date. She confirmed with the facility that the resident had run out earlier than expected, documented a medication error, and was told by facility leadership that there was an active investigation into narcotic diversion and that a nurse was suspected. Unit Manager #1 and hospice staff confirmed that a whole 30-tablet card for this resident was missing from the medication cart, and the DON acknowledged she had no evidence of an investigation specific to this resident’s missing medication. Throughout both cases, required narcotic control records were missing, narcotic counts and documentation were inconsistent, and the facility did not maintain or produce complete investigative records regarding the missing Hydrocodone-Acetaminophen for either resident.