F0602

E

Misappropriation and Poor Control of Residents’ Narcotic Medications

Pittsburgh, Pennsylvania Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to protect residents from misappropriation of property by not ensuring accurate control, documentation, and safeguarding of multiple residents' controlled medications. Facility policies on Abuse, Neglect & Exploitation and on Medication Ordering and Receiving from Pharmacy required protection of resident property and special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, controlled substance records for several residents showed discrepancies between documented administration and remaining pill counts, and in one case, the absence of any controlled substance record for a prescribed PRN narcotic.

For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed for pain. Review of the controlled substance record for MS Contin 15 mg showed that on a specific date the resident was documented as receiving two tablets, with a starting count of 25 and an ending count of 21, which did not reconcile. For MS Contin 30 mg twice daily, the record showed that on two dates the resident was documented as receiving three tablets, with a starting count of 18 and an ending count of 11, again not reconciling. Additionally, there was no controlled substance record for the resident’s Oxycodone 5 mg PRN from the date of order initiation through the date of review, even though the pharmacy confirmed dispensing 18 tablets. Another resident with coronary artery disease, COPD, and osteoarthritis had an order for Oxycodone 7.5 mg every eight hours as needed; the controlled substance record showed that on two dates the resident was documented as receiving one tablet, with a starting count of 40 and an ending count of 36, which did not match the documented usage.

A third resident with high blood pressure, depression, and spina bifida had an order for MS Contin 15 mg three times daily. The controlled substance record indicated that on two dates the resident was documented as receiving two tablets, with a starting count of 38 and an ending count of 32, reflecting a discrepancy. A fourth resident with high blood pressure, depression, and neuropathy had an order for Oxycodone 5 mg every 12 hours as needed; the record showed that on one date the resident was documented as receiving one tablet, with a starting count of 12 and an ending count of 9, which did not reconcile. A fifth resident with heart failure, COPD, and muscle spasms had an order for Oxycodone 10 mg three times daily; the controlled substance record showed that on two dates the resident was documented as receiving four tablets, with a starting count of six and an ending count of two, while the resident was reported to have slept all night.

Staff interviews further described events surrounding these discrepancies. A RN supervisor reported working a double shift while an agency RN worked the overnight shift; the oncoming RN identified that one resident’s Oxycodone count was four tablets short. The agency RN stated she might have given a double dose and could not account for the remaining tablets. The RN supervisor notified the DON and adjusted the narcotic count so the oncoming nurse could begin medication administration. Another RN later noted that while her narcotic counts were correct at shift change, the controlled substance records contained documentation discrepancies, including inconsistent count changes for one resident’s MS Contin and documentation of Oxycodone administration to another resident who had reportedly slept all night. The Nursing Home Administrator and DON acknowledged that an agency RN allegedly took multiple residents’ narcotics and confirmed that the facility failed to ensure residents were free from misappropriation of property. The facility did not provide documentation showing that the missing narcotics were reported to the Department of Health.