F0602

D

Misappropriation and Improper Handling of Controlled Pain Medications

Indianapolis, Indiana Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to protect residents from misappropriation of controlled pain medications and improper handling and documentation of narcotics. Resident B, who had diagnoses including ankylosing spondylitis and muscle weakness and was documented as cognitively intact, reported that staff told him his pain medication was missing. His physician’s order authorized oxycodone/acetaminophen 10/325 mg, one tablet orally every six hours for pain. Pharmacy records showed that 40 tablets of this medication were delivered for him, and the controlled drug record reflected a starting balance of 40 tablets with no doses signed out as administered. A facility investigation included conflicting staff statements: one QMA stated the DON removed Resident B’s oxycodone/acetaminophen from the locked cart, while the DON stated she removed several medications from carts but none for Resident B and did not know what happened to his medication. The pharmacy indicated Resident B should have had 40 tablets available in the locked cart, but they were missing.

The deficiency also includes improper documentation and handling of controlled substances for Resident C. Resident C had diagnoses including paraplegia, diabetes, and anxiety and was documented as cognitively impaired. A physician’s order authorized oxycodone/acetaminophen 5/325 mg, two tablets every eight hours as needed for pain. On a narcotic administration record, an LPN initialed that she removed two oxycodone/acetaminophen 5/325 mg tablets for Resident C under one prescription number at a specific time, and also documented removal of two additional oxycodone/acetaminophen 5/325 mg tablets for Resident C under a different prescription number at the same time. A handwritten statement indicated the LPN had been made aware that Resident C’s physician’s order for oxycodone/acetaminophen 5/325 mg had been changed, yet the records still showed these removals and administrations.

For Resident D, who had diagnoses including dementia, epilepsy, and cognitive communication deficit, a physician’s order authorized hydrocodone/acetaminophen 5/325 mg, one tablet orally four times daily for pain. The controlled drug record showed that the same LPN signed out two hydrocodone/acetaminophen 5/325 mg tablets for Resident D at a specific time, exceeding the ordered single-tablet dose. An undated written statement from the attending physician confirmed that no one-time order had been given to administer an extra tablet of hydrocodone/acetaminophen 5/325 mg on that date. The facility’s abuse prevention policy stated that each resident has the right to be free from misappropriation, yet the documented missing narcotics and unexplained extra doses for multiple residents demonstrate failures in protecting residents’ property and in accurate narcotic documentation and handling.