F0609

D

Failure to Properly Classify and Timely Report Missing Controlled Medications

Torrington, Connecticut Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly identify, document, classify, and timely report an allegation of misappropriation of controlled medications belonging to multiple residents. Resident #2 had diagnoses including lumbar spine fusion, bipolar disorder, and depression, with an order for PRN Oxycodone for pain and a care plan intervention to administer pain medication as ordered. Resident #3 had dementia with severe cognitive impairment, an order for PRN Oxycodone for pain that was later discontinued, and a care plan identifying risk for pain with an intervention to administer pain medication as ordered. Resident #4 had anxiety with severely impaired cognition, a care plan for anxiety with an intervention to administer anti-anxiety medication as ordered, and a PRN Lorazepam order that was later discontinued.

A facility reportable event form dated 11/20/2025 identified that discontinued medications scheduled to be destroyed appeared to be missing, but the form did not identify which residents were affected or what specific medications were involved. Additional information later documented that disposition sheets for controlled medications were missing and that the medications were last seen during an audit, with missing quantities including 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility reportable event summary identified that a drug audit had found missing narcotics scheduled for collection as discontinued medications, specifying that 9 tablets of Oxycodone for Resident #2, 28 tablets of Oxycodone for Resident #3, and 15 tablets of Lorazepam for Resident #4 were missing. The facility’s incident report for the same event stated that discontinued medications scheduled to be destroyed appeared to be missing but again did not list any of the affected residents.

The State Agency online portal showed that the reportable event was submitted on 11/20/2025 for an incident identified as occurring on 11/10/2025, resulting in a 10-day delay in reporting. The event was initially misclassified as a Class C (loss of heat/water/emergency systems or evacuation) before being changed to a Class B (abuse), and the DON reported that she did not classify the incident as misappropriation, instead selecting “other,” because the medications had been discontinued and should have been destroyed. Interviews with the DON and Corporate RN #1 confirmed that the medications and related documentation were identified as missing on 11/9/2025, that the State Agency was not notified of the resident names, and that they did not consider the situation a potential misappropriation despite facility policy defining misappropriation as the deliberate misplacement or use of a resident’s belongings without consent and requiring immediate reporting of alleged violations. The facility’s Accident and Incident Policy also required that incident reports include the names of individuals involved and a detailed description of the event and resident condition, which was not done in this case.