F0602

E

Misappropriation of Controlled Pain Medications for Two Residents

Waco, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of property, specifically controlled pain medications, for two residents reviewed. For the first resident, an older female with hemiplegia, vascular dementia, chronic pain syndrome, and severe cognitive impairment, the physician had ordered hydrocodone-acetaminophen 7.5/325 mg via PEG tube three times daily for pain. Pharmacy records showed that 124 tablets of this medication were delivered and received by LVN A, but the facility’s narcotic count sheet documented only 64 tablets, with the quantity changed from 124 to 64. This discrepancy was discovered when a nurse attempted to reorder the narcotic and the pharmacy reported it was too soon, leading to the identification of 60 missing tablets for this resident.

For the second resident, an older male with paraplegia, Type 2 diabetes, heart disease, muscle wasting, and major depressive disorder, the physician had ordered hydrocodone-acetaminophen 10/325 mg every six hours as needed for pain. The narcotic count sheet for this resident showed that 60 tablets were received on a specific date, but the signature of the receiving staff member was missing, and only a date and amount were recorded. Pharmacy records, however, reflected that 90 tablets were delivered for this resident and received by LVN B, who reported handing the medication off to LVN A. Review of the narcotic count sheets revealed that 30 tablets of hydrocodone-acetaminophen 10/325 mg were missing for this resident.

Interviews with facility leadership and the physician confirmed that the discrepancies in narcotic counts for both residents were identified during internal review of narcotic records. The DON stated that LVN A had received the hydrocodone-acetaminophen for the first resident and that the quantity on the narcotic count sheet had been altered, with no witnesses to the change. For the second resident, the DON noted that the handwriting on the narcotic count sheet entry for receipt resembled that of LVN A, again without witnesses and without a staff signature. The administrator and physician both described expectations that narcotics be managed without errors, diversion, or missing medications, and the facility’s abuse, neglect, and exploitation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. Attempts to contact LVN A for an interview were unsuccessful, and the second resident reported awareness of the missing medications but stated he was not personally affected and had no concerns with his pain management.