Unsecured Hydrocodone Tablets Left at Nurse’s Station and Subsequently Missing
Penalty
Summary
The deficiency involves the facility’s failure to securely store controlled medications in accordance with professional standards and facility policy. On the 400 hall, an LVN received a delivery of hydrocodone-acetaminophen 5-325 mg tablets for a male resident with Type 2 diabetes, senile degeneration of the brain, and unspecified dementia. The resident had an order for one tablet by mouth every 8 hours as needed for pain, with a 30‑day supply (90 tablets) last filled on 1/15/2026 and a next fill date of 2/10/2026. On 2/10/2026 at approximately 3:00 p.m., after another nurse co-signed for receipt of the controlled medication, the LVN placed the hydrocodone medication card containing 45 tablets on the desk at the nurse’s station instead of immediately locking it in the medication cart as required. The LVN then began charting and kept the hydrocodone tablets at the nurse’s station for approximately two hours. During this time, she became distracted, left the nurse’s station to respond to a resident’s needs, and forgot to secure the narcotics. When she returned, the medication card was missing. The LVN later documented that she had set the card down beside her while charting and that she was unable to locate the medication after searching medication carts, medication rooms, supply closets, and the treatment cart. Other LVNs working that day reported seeing the LVN take delivery of the medication but did not see whether it was locked up, and they did not observe the medication lying out in the open or residents near the nurse’s station counter during the relevant timeframe. Record review showed that the resident had received a dose of hydrocodone-acetaminophen earlier that morning at 7:30 a.m., with 30 tablets remaining on the narcotic administration log, and that the resident had an as‑needed order for moderate to severe pain. Subsequent observation of the resident found him seated in a wheelchair in a common area watching television, appearing calm and in no acute distress, with no facial grimacing or observable signs of physical distress. The resident reported that he took pain medication as needed, that it was always available when requested, and that it effectively controlled his pain. The facility’s written policy for controlled medications stated that Schedule II medications are to be stored under double lock in a locked cabinet or safe, separate from all other medications, which was not followed in this incident.
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