F0755

D

Failure to Control and Account for Discontinued Narcotic Medications

Torrington, Connecticut Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain adequate controls over narcotic medications, resulting in the misplacement and loss of controlled substances for multiple residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN Oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. Another resident with dementia had a PRN Oxycodone order for pain, and a third resident with dementia and anxiety had a PRN Lorazepam order for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that one resident did not receive the ordered Oxycodone.

A reportable event documented that discontinued medications scheduled for destruction were missing, but the initial form did not identify which residents or which medications were involved. Later information identified that disposition sheets for controlled medications were missing and that the medications were last seen during an audit. The missing medications were specified as 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility summary further detailed that a drug audit identified missing narcotics that had been discontinued and last observed weeks to months earlier, including nine Oxycodone tablets for one resident, 28 Oxycodone tablets for another resident, and 15 Lorazepam tablets for a third resident. The investigation did not identify the person responsible for the missing medications, and the last recorded medication disposal before the loss was more than a month earlier.

Interviews and documentation showed that the white controlled substance disposition records and matching medication packs were missing from the unit narcotic books and lock boxes. The medications had been moved to the back of the narcotic lock boxes on the medication carts for future removal for destruction instead of being removed immediately to a secured lock box in the nursing office, as required. The RN involved stated she did not know why the narcotics were not removed when discontinued. An LPN who conducted narcotic audits reported that her audits did not include review of the MAR and that when discrepancies were found, she adjusted counts to match the white proof-of-use sheets. Audit records showed a discrepancy in one resident’s Oxycodone count and missing required dual nurse signatures for end-of-shift narcotic counts on multiple dates and shifts. The facility’s own policy required immediate documentation of controlled substances, shift-change counts by two licensed nurses, and timely return of discontinued controlled drugs to a double-locked cabinet in the nursing office, but these procedures were not consistently followed, leading to the misappropriation of narcotics.