F0607

D

Failure to Immediately Report and Investigate Missing Narcotic Medication

Marion, North Carolina Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse, Neglect and Exploitation policy requiring immediate reporting of all allegations and suspicions of misappropriation of resident property, including narcotics, to the Administrator/Abuse Coordinator. The policy stated that once notified, the Administrator/Abuse Coordinator would immediately begin an investigation and notify applicable local and state agencies. In this case, the facility became aware through the pharmacy that seven 5 mg tablets of Oxycodone, a narcotic pain medication belonging to Resident #134 and contained in a sealed Controlled Medication Return Bag, were missing after the resident had been discharged. This information was first relayed to the facility on 4/10/2025 when pharmacy staff attempted to contact the facility about an issue with narcotic medication that was supposed to be returned.

According to interviews, the ADON was informed on 4/10/2025 by a floor nurse that the pharmacy was on the phone regarding an issue with narcotic medication sent back to the pharmacy, but when the ADON got to the phone, the pharmacy was no longer on the line and she did not attempt to call the pharmacy back. The pharmacy called again on 4/11/2025 and informed the ADON of the missing Oxycodone for Resident #134. The ADON did not notify the DON of the missing narcotics until 4/12/2025, stating she did not know missing narcotics had to be reported immediately and wanted to wait to see if the pharmacy could locate the medication. The DON then delayed notifying the Administrator until 4/14/2025 because he did not know that missing narcotics was a reportable event that required immediate notification and investigation. As a result, the Administrator was not informed of the allegation of misappropriation until several days after the facility first became aware of the missing narcotics.

During this period of delayed reporting and investigation, nursing staff who were later identified in the facility’s investigation as involved in the handling of the narcotic returns continued to work. Time records showed that one nurse worked multiple overnight shifts from 4/12/2025 through 4/15/2025, and another agency nurse worked shifts spanning 4/10/2025 through 4/12/2025 after the ADON had been notified by the pharmacy of the missing Oxycodone and before the facility initiated its investigation. Law enforcement notification was also delayed and not clearly documented. The facility’s Initial Allegation Report listed that a police officer was called on 4/15/2025, but the officer reported there were no records of any calls or emails from the facility regarding missing narcotics during that time, and the DON’s call log only showed a call to the officer’s direct number on 4/18/2025. These actions and inactions demonstrate that the facility did not follow its own abuse, neglect, and exploitation policy for immediate reporting and investigation of suspected misappropriation of resident property.