F0755

D

Failure to Reconcile and Secure Narcotics Resulting in Missing Oxycodone Tablets

Marshville, North Carolina Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain effective systems for shift-change narcotic reconciliation and to keep discontinued narcotic medications secured under two locks, resulting in missing controlled substances for two residents. For one resident, there was a physician’s order for oxycodone/acetaminophen 10/325 mg, one tablet by mouth twice per day as needed for moderate pain. The medication administration record showed that this resident received a dose on one morning for severe pain rated 9/10, administered by a medication aide (MA) and documented as effective. The MA reported that on the prior afternoon narcotic count, she recalled seeing a full card of 30 tablets of oxycodone/acetaminophen in the locked narcotic drawer for this resident.

On the following morning, the MA was scheduled to work the day shift and received report and the medication cart from a nurse who had worked the prior afternoon and night shifts. The MA and the nurse counted narcotics on one hall’s cart and found the count accurate. However, when they went to count the narcotics on the second cart, the nurse told the MA that the count was the same as the previous afternoon and that they did not need to perform the count. The MA acknowledged that she knew she should not skip the narcotic count but relied on the nurse’s verbal assurance and signed the narcotic count sheet without physically counting the narcotics on that cart. Later that morning, when the resident requested pain medication, the MA opened the locked narcotic drawer and discovered that the resident’s oxycodone/acetaminophen blister pack was missing, despite her knowledge that a full card had been present the previous day.

The facility’s internal investigation and interviews confirmed that the narcotic count for that cart had not been properly completed at shift change, and that the missing oxycodone/acetaminophen for this resident could not be located. Pharmacy records confirmed that 60 tablets had been delivered, and the facility determined that 50 tablets of oxycodone/acetaminophen 10/325 mg for this resident were missing. The former DON and unit manager both stated that nurses and medication aides, including the involved staff, had been trained to complete narcotic counts at every shift change, but in this instance the process was not followed, and staff relied on verbal confirmation rather than a physical count.

A second deficiency involved discontinued narcotic medications for another resident who had a physician’s order for oxycodone 5 mg via gastric tube every four hours as needed for pain and who had died a few days before the events described. A nurse removed this resident’s narcotic medications from the locked narcotic drawer, placed them in a clear pharmacy return bag, and left the bag in the medication room. The next morning, the same MA was informed by the nurse that there were medications on the counter in the medication room that needed to be returned to the pharmacy. The MA, aware that the resident had died and that medications needed to be returned, took the bag from the medication room to the unit manager at the main nurse’s station but did not look inside the bag or verify its contents. The unit manager, who was occupied with investigating the first resident’s missing narcotics, placed the bag in an unlocked cabinet behind the nurse’s station instead of securing it under double lock as required.

Later that day, when the unit manager and another nurse prepared to return medications to the pharmacy, they followed the process requiring two nurses to count and scan medications for return. At that time, they discovered that the oxycodone 5 mg tablets prescribed for the deceased resident were missing from the return bag. The unit manager acknowledged that she should have locked the medications in a locked cabinet in the medication room but failed to do so. The former DON stated that the unit manager was aware that narcotic medications needed to be locked, and the regional clinical leader stated that discontinued narcotics were to be kept under two locks until pharmacy retrieval with two nurses signing them out. The investigation determined that 30 tablets of oxycodone 5 mg for this resident could not be accounted for and that the medications had not been continuously secured under a double-lock system.

Overall, the events leading to the deficiency consisted of staff failing to complete required shift-change controlled substance counts by physically verifying narcotics, relying instead on verbal confirmation, and failing to maintain discontinued narcotics under required double-lock security. These actions and inactions resulted in a total of 80 missing oxycodone-containing tablets for two residents, with the facility unable to substantiate the misappropriation or determine what happened to the medications.