F0602

E

Failure to Safeguard and Account for Controlled Pain Medications

Lumberton, North Carolina Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of their controlled pain medications and to maintain required controls over these drugs. For nine residents with active orders for narcotic or controlled pain medications (including tramadol, oxycodone, hydrocodone-acetaminophen, and oxycodone-acetaminophen), pharmacy records showed that multiple prescriptions were filled and delivered to the facility, but there were no corresponding declining count sheets or complete delivery documentation. In several instances, delivery receipts were signed by only one nurse instead of two, and in some cases there was no nurse signature at all. The Director of Nursing (DON) later confirmed that the medications for these residents were never entered into the narcotic records and that the declining count sheets were missing.

For each of the nine residents, the surveyors verified that controlled medications had been ordered by a practitioner and dispensed by the pharmacy, but the facility lacked the required inventory logs to track receipt and use of these medications. For example, one cognitively intact resident with an order for scheduled tramadol had 30 tablets documented as delivered by the pharmacy, signed as received by a night-shift nurse, but no second nurse signature and no declining count sheet could be found. Another resident with severely impaired cognition and an as-needed oxycodone order had two separate deliveries of 60 tablets each documented by the pharmacy, yet there were no nurse signatures on one delivery sheet and no declining count sheets for either shipment. Similar patterns occurred for residents with diagnoses such as cancer, heart failure, CVA, arthritis, diabetes, renal disease, and deep vein thrombosis, all of whom had active controlled medication orders and documented pharmacy deliveries without corresponding facility inventory records.

Interviews and record reviews showed that the facility’s process for handling controlled medication deliveries contributed to the deficiency. The DON stated that when controlled medications were delivered, whichever nurse was available would distribute medications from the delivery tote to the medication carts and sign the delivery sheet, even though the form had two signature lines intended for both the nurse checking in the medications and the nurse receiving them on the cart. The DON acknowledged that two nurses were not consistently signing the delivery sheets, that she did not verify that medications documented as delivered were actually placed on the carts, and that missing medications were not recorded in the narcotic book. An internal audit initiated after one resident’s tramadol could not be located revealed that eight additional residents had missing controlled medications for active orders, and the facility ultimately identified a total of 660 missing controlled tablets for active orders. Staff interviews indicated that a specific medication aide had been acting suspicious, and subsequent drug testing of staff showed that this aide tested positive for the missing medications, coinciding with the period in which the controlled medications and required documentation were absent.

Additional interviews with the Chief Nursing Officer, Nurse Consultant, pharmacy director, and nurse practitioners further described how ordering and dispensing practices led to excessive quantities of controlled medications being present on medication carts without adequate tracking. One nurse practitioner reported that during monthly pain assessments she routinely ordered refills for controlled pain medications without first checking with nursing staff to determine if refills were needed, and the pharmacy director stated that the pharmacy would refill controlled medications when orders were received if they had not been filled in a while. These practices resulted in large amounts of controlled medications being stored on the carts. Although facility leadership and pharmacy representatives later described changes to ordering and refill processes, the surveyors noted that the facility-provided corrective action plan could not be validated.