F0602

D

Narcotic Diversion and Failure to Administer Prescribed Pain Medication

Spokane, Washington Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a prescribed narcotic medication (Norco 10/325 mg) was administered to the resident for whom it was ordered and not diverted for other use. A clear pouch containing two Norco tablets was found on the floor at the second-floor nurse’s station by the Administrator at 7:00 AM, and review of all residents’ medication orders showed that only one resident in the facility had an active prescription for this medication. Review of the narcotic logbook showed that a registered nurse had signed out doses of Norco for this resident during the night, including one dose at 11:30 PM and another at 5:00 AM. The Medication Administration Record documented that the 11:30 PM dose was given, but there was no documentation that the 5:00 AM dose was administered. When interviewed, the nurse stated the medication had been given and could not explain the pouch found on the floor. The resident, who had chronic back pain, reported not recalling receiving pain medication and not being awakened during the night for care or medication.

Further review of records identified that two additional registered nurses had also signed out Norco for the same resident and documented administration over several days. A urine drug screen was ordered for the resident to check for the presence of narcotic medication, and the result was negative. The facility consulted with the laboratory and was informed that Norco would be detectable in urine within one to two days of administration. After additional consultation with the resident’s provider, it was determined that narcotic diversion had occurred. The facility’s investigation substantiated that the narcotic medication signed out for this resident had not been properly administered as ordered and had instead been diverted by nursing staff.