F0607

D

Failure to Investigate and Report Alleged Misappropriation of Narcotic Pain Medication

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding investigation and reporting of alleged misappropriation of narcotic medications for two residents receiving Hydrocodone-Acetaminophen. The written policy required the facility to exercise caution in handling potential evidence, focus investigations on whether misappropriation occurred, thoroughly document investigations, and report all alleged violations to the state agency, APS, and law enforcement when applicable within 24 hours. Despite these requirements, the facility did not complete or retain thorough investigative documentation and did not report the allegations to required external agencies. The Administrator and DON instead treated the events primarily as a human resources issue involving a nurse, and the Administrator believed that the payer source (hospice) determined whether misappropriation from a resident had occurred.

For one resident, a physician’s order for Hydrocodone-Acetaminophen 5-325 mg every 4 hours as needed for pain was initiated, and the local pharmacy dispensed 30 tablets that were picked up, followed by another 30 tablets delivered later and signed for by a nurse. During a narcotic count, a med aide discovered that the Hydrocodone-Acetaminophen for this resident was missing from the medication cart. The DON’s written statement referenced missing narcotic medication in October but did not identify the resident, and the DON later could not recall which resident was affected. The facility was unable to locate the medication monitoring/control records for the Hydrocodone-Acetaminophen delivered for this resident. The DON reviewed staffing and identified that only one nurse and two med aides had responsibility for the cart during the relevant period, interviewed them, and confirmed that the medication container had previously been on the cart. The nurse who had signed for the narcotics reported no recollection of what happened to the medication, and her response was described as unprofessional. The DON suspended and ultimately terminated this nurse, but the facility did not report the misappropriation to the state agency, APS, law enforcement, or a licensing authority.

For the second resident, a physician’s order for Hydrocodone-Acetaminophen 5-325 mg every 8 hours for pain was initiated, and the pharmacy dispensed 43 tablets (30 on one card and 13 on another), which were delivered and signed for by the same nurse. MAR documentation showed scheduled administration three times daily, and a med aide later documented that the resident did not receive a scheduled dose because the facility was awaiting pharmacy delivery. Hospice staff reported that this resident should not have run out of Hydrocodone-Acetaminophen until a later date, but on one day in October they were informed the resident had run out and that an active investigation into narcotic diversion was underway. Hospice personnel clarified that the medication belonged to the resident, not hospice, and that hospice did not have responsibility for investigating or reporting diversion within the facility. The DON could not locate the medication monitoring/control record for the 30-tablet card and only produced the record for the 13-tablet card, which showed the medication ran out earlier than expected. The DON stated she had initiated a diversion investigation, checked all medication carts, and interviewed staff, but no discrepancies were found on the carts at that time because the 30-tablet card and its record were not present. The DON and Administrator acknowledged that documentation of the investigation was lost or misplaced, that the nurse involved was suspended and later terminated, and that they did not report the misappropriation to external authorities, based on their belief that hospice ownership of the medication meant it was not misappropriation from a resident.

Hospice staff from both hospice providers consistently reported that the Hydrocodone-Acetaminophen belonged to the residents, not to hospice, and that hospice nurses did not have the responsibility or ability to investigate or report narcotic diversion within the facility. One hospice nurse reported being told by the Administrator that there was an open investigation into drug diversion and a suspected nurse, but no follow-up information was provided. The DON and Administrator both stated that they believed hospice would conduct its own investigation and reporting because hospice was the payer source. The facility’s inability to identify the affected resident in one case, the missing medication monitoring/control records for both residents’ narcotics, the loss of all investigative documentation, and the failure to report the allegations to the state agency, APS, law enforcement, or licensing authorities demonstrate that the facility did not follow its own abuse, neglect, and exploitation policy regarding investigation, documentation, and reporting of alleged misappropriation of resident medications.