F0610

E

Failure to Investigate Alleged Misappropriation of Controlled Medications

Pittsburgh, Pennsylvania Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a thorough investigation into allegations of misappropriation of resident property, specifically missing controlled substances, for five residents. Facility policy on Abuse, Neglect, & Exploitation required written procedures to prohibit misappropriation of resident property, and the Medication Ordering and Receiving from Pharmacy policy required special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, multiple discrepancies were identified in narcotic counts and documentation for several residents’ controlled medications, and the facility did not complete an investigation into these discrepancies or the alleged diversion by an agency RN.

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. Review of the controlled substance records showed that for MS Contin 15 mg, the record documented two tablets given with a starting count of 25 and an ending count of 21, and for MS Contin 30 mg, three tablets were documented as given over two days with a starting count of 18 and an ending count of 11. No controlled substance record was found for the resident’s Oxycodone 5 mg PRN from 1/18/26 through 2/25/26, although the pharmacy confirmed that 18 tablets had been dispensed. Similar discrepancies were found for another resident with coronary artery disease, COPD, and osteoarthritis, whose Oxycodone 7.5 mg PRN count decreased from 40 to 36 while documentation indicated only two tablets were given.

Additional residents were affected. One resident with high blood pressure, depression, and spina bifida had MS Contin 15 mg three times daily ordered; the controlled substance record showed the count going from 38 to 32 while documentation indicated only two tablets were given over two days. Another resident with high blood pressure, depression, and neuropathy had Oxycodone 5 mg every 12 hours PRN ordered; the count went from 12 to 9 while documentation indicated one tablet given. A fifth resident with heart failure, COPD, and muscle spasms had Oxycodone 10 mg three times daily ordered; the record showed four tablets documented as given over two days, with the count going from six to two, while the resident was reported to have slept all night. Staff interviews described that an agency RN worked the overnight shift when the discrepancies occurred, appeared shaky and emotional, and gave inconsistent explanations for missing tablets. The DON and NHA acknowledged that missing narcotics from those dates were known, that police were present, and that the DON had not conducted or produced an investigation into the alleged narcotic diversion or misappropriation, and the missing narcotics were not reported to the Department of Health.