F0602

E

Misappropriation and Tampering of Residents’ Narcotic Medications

Jacksonville, Illinois Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their prescribed narcotic medications. On one occasion, a nurse identified that several bottles of liquid morphine intended for residents were discolored and had a different consistency than usual. Facility documentation and staff interviews state that morphine in seven bottles, associated with four residents, appeared clear and watery instead of the usual pink and more viscous solution. Narcotic counts conducted around shift changes did not initially show discrepancies, and staff verified that the morphine had been the correct pink color when administered on prior shifts, indicating that the contents were switched to a clear liquid sometime after the last accurate count.

The affected residents were receiving morphine for significant pain and symptom management. One resident had an order for concentrated morphine sulfate 20 mg/mL, 0.25 mL by mouth every hour as needed for pain or shortness of breath and had a diagnosis of polyneuropathy. Another resident was ordered morphine sulfate 10 mg/5 mL, 0.25 mL every two hours as needed for pain or shortness of breath, with diagnoses including partial intestinal obstruction and palliative care. A third resident had an order for morphine sulfate 20 mg/5 mL, 0.25 mL every two hours as needed for severe pain or air hunger and a diagnosis of compression fracture of the thoracic vertebra. A fourth resident was ordered concentrated morphine sulfate 100 mg/5 mL, 0.25 mL every hour as needed for pain, with diagnoses including diabetic neuropathy and a history of healed traumatic fracture. Staff interviews and facility reports confirm that the morphine for these residents had been altered and that the liquid in the bottles did not match the expected color and viscosity.

A separate incident involved misappropriation of a different resident’s hydrocodone-acetaminophen (Norco). This resident, who had chronic back pain, was on hospice for heart failure and dysphagia and had an order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth three times daily for pain, not to exceed 4 g/day. Facility documentation and staff interviews state that an entire card of 60 hydrocodone tablets for this resident went missing over a period of days. Narcotic counts before and after the disappearance confirmed that the card had been present during one count and was no longer present at a subsequent count, and the card was never located. In both the morphine and hydrocodone incidents, the facility’s own reports and staff statements confirm that residents’ prescribed narcotic medications were either altered or missing and that the responsible individual was not identified, resulting in misappropriation of residents’ personal property in the form of their medications.