Misappropriation of Controlled Drugs and Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property, including controlled medications and personal funds. One cognitively intact resident, R9, had active orders for oxycodone 5 mg in multiple dosing schedules for chronic pain related to encephalopathy, cellulitis of both lower limbs, CHF, bilateral lower extremity contractures, chronic pain, low back pain, depression, and localized edema. R9 reported ongoing pain in his feet and buttocks and stated that his pain medication had been misplaced in the past. On March 6, 2026, staff noted that a card containing 43 tablets of oxycodone 5 mg and the associated narcotic count sheet were missing from the medication cart, and when a nurse attempted to administer oxycodone to R9 that morning, there was no oxycodone available despite an expectation that another card with 48 tablets should have been present. The facility’s internal review and video surveillance showed that an agency RN, identified as V19, removed the narcotic card from the narcotic drawer, placed it on top of the medication cart, turned her back to the camera, then placed the card between papers and put these items into her personal bag. She was then seen exiting the building with the bag, placing it in her vehicle, and returning to the facility without the bag. Multiple attempts by facility leadership to contact this RN for verbal and written statements were unsuccessful. The missing oxycodone card and narcotic count sheet were not located despite searches of the building, medication carts, and narcotic drawers, and no other missing items were identified at that time. A second cognitively intact resident, R3, experienced misappropriation of personal funds. R3 discovered she had virtually no money remaining in her bank account after reviewing a bank statement and reported this to the business office manager. Bank records showed multiple debit transactions for services such as DoorDash, Uber, and Lyft that R3 stated she did not make. R3 reported that her debit card had been kept in a coin purse in a drawer, that she had never given anyone permission to use her card without her being present, and that she believed someone from the facility took her card. The administrator confirmed that R3 did not use these services and that the charges, totaling $186.35, were associated with local vendors near the facility. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent and states that the facility will provide oversight and supervision of staff to ensure implementation of these policies.
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