F0602

D

Misappropriation of Controlled Narcotic Medications by Nursing Staff

Bristol, Connecticut Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of their controlled narcotic medications, specifically Hydromorphone and Oxycodone, for three residents. One resident with lumbar compression fracture, spinal stenosis, and heart failure was admitted with severe back pain and had an order for Hydromorphone 2 mg every six hours as needed. The resident was alert, oriented, and required moderate assistance for walking, and the care plan directed staff to administer pain medications as ordered. A subsequent physician order discontinued the Hydromorphone. During a controlled medication audit on the same day, the facility identified that the original white Controlled Substance Disposition Record (Proof of Use Sheet) and the associated blister card of 28 Hydromorphone 2 mg tablets were missing from the locked medication cart. Earlier that morning, the narcotic count completed by two LPNs showed the count as correct, and a later audit by the ADNS also verified the count and Proof of Use sheets as correct. Later that afternoon, the DON found that the Proof of Use sheet for the Hydromorphone blister pack was missing from the narcotic book and, upon checking the locked medication box after the assigned nurse left the unit, determined that the blister pack of 28 tablets was not present.

Another resident, admitted after a right hip replacement with osteoarthritis and effective pain control, had physician orders for Hydromorphone 2 mg and 4 mg by mouth every four hours as needed for moderate and severe pain, respectively, with instructions to hold for sedation or shortness of breath and report to the provider. The resident’s care plan identified pain related to osteoarthritis and a medical procedure, with interventions to administer medications as ordered. A narcotic audit identified that a newly delivered blister pack of fifteen Hydromorphone 2 mg tablets and the corresponding white disposition sheet were missing from the unit narcotics lock box. The Hydromorphone blister pack had been received from the pharmacy three days earlier, and the DON’s review showed that the Proof of Use sheet was missing from the narcotic book three days after delivery. The DON narrowed possible staff involvement to three nurses but was unable to determine which nurse was responsible. A state Drug Control Division report later documented that two blister packs of Hydromorphone had been delivered and that an LPN on the 3–11 PM shift had confirmed receipt of the Hydromorphone for this resident.

A third resident, admitted with a displaced left femur fracture and left hip replacement, was cognitively intact with a BIMS score of 15 and reported occasional pain. The care plan identified pain related to the fracture, with interventions to evaluate pain relief effectiveness and respond immediately to pain complaints. A physician ordered Oxycodone 5 mg, one tablet every four hours as needed for moderate hip pain and two tablets for severe hip pain. A reportable event documented that a new blister pack of fifteen Oxycodone 5 mg tablets and the matching white Proof of Use sheet were missing from the narcotic lock box. The facility had received two blister packs of Oxycodone 5 mg, each containing fifteen tablets, but only one blister pack was present in the lock box, and the MAR showed that no Oxycodone doses had been administered. An audit identified that the Proof of Use sheet for the missing Oxycodone blister pack was not included in the narcotic count on a prior evening, with the number of sheets in the book decreasing between the afternoon and late-night counts. The DON’s investigation suspected diversion but did not determine how the Oxycodone went missing. Across all three incidents, the DON identified the same LPN in connection with each investigation and concluded that the missing narcotics for these residents were likely taken by that LPN, while the facility’s abuse policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent.

The facility’s established system required two nurses to complete shift-to-shift narcotic counts, comparing the number of tablets in the locked medication box to the remaining count on the Proof of Use sheets, including counting the sheets themselves and signing off at each shift change. Any discrepancy was to be reported to a supervisor for immediate investigation. Despite these procedures, the missing Hydromorphone and Oxycodone blister packs and their associated Proof of Use sheets were not detected until audits revealed that both the medications and documentation were absent from the narcotic lock boxes and books. In each case, the missing medications were newly delivered controlled substances that had not been documented as administered, and the facility’s investigations did not establish how the medications were removed, resulting in misappropriation of residents’ controlled narcotic medications in violation of the facility’s abuse policy and residents’ rights to be free from misappropriation of property.