F0602

G

Misappropriation and Diversion of Medications From Cognitively Impaired Residents

Plainville, Kansas Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent misappropriation and diversion of resident medications, including controlled substances, for 15 cognitively impaired residents, resulting in missed doses. A certified medication aide (CMA) was observed on camera removing a black trash bag from the medication cart, carrying it to the soiled utility room, and leaving it there. Review of the footage showed the CMA popping medications out of residents’ bubble packs, placing some pills into a medication cup and then into a black trash bag, and placing other popped medications into a medication cup stored in the top left-hand drawer of the medication cart. The controlled substance drawer was unlocked while pills were being placed into cups in that drawer, and subsequent review determined that nine controlled substances or muscle relaxers popped from residents’ medication cards were not accounted for.

The incident came to light when laundry staff discovered a black trash bag containing numerous pills at the bottom of a soiled laundry barrel in the utility room and reported it to nursing staff. Administrative staff later identified 43 pills in the bag belonging to 15 different cognitively impaired residents. The facility’s records showed that these residents did not receive multiple ordered medications during the night in question, including psychotropics, anticonvulsants, opioids, anticoagulants, antibiotics, muscle relaxants, sleep aids, and other medications such as stool softeners, cholesterol medications, and pain medications. 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 without consent, and the actions of the CMA were determined to be targeted toward residents with cognitive impairment who would not remember whether they had received their medications.

Specific resident records documented clinical outcomes associated with the missed medications. One resident with Alzheimer’s disease, dementia, pain, mood disturbance, and anxiety, who was ordered antipsychotics, anticonvulsants, opioids, and other medications, did not receive several of these medications that night and later reported feeling disrespected, wanting to leave the facility, feeling ugly, and having back pain that limited mobility. Another resident with Alzheimer’s disease, dementia, and anxiety, ordered antianxiety and opioid medications, did not receive tramadol, lorazepam, melatonin, and gabapentin, and was documented as very restless and up to the bathroom multiple times through the night. A third resident with major depressive disorder, psychosis, anxiety, impaired cognition, and psychotropic use did not receive an antibiotic, antidepressant, antipsychotic, and gabapentin, and was documented as expressing delusional beliefs about being held captive and needing to leave at midnight. Other affected residents missed various medications, and all 15 residents involved were cognitively impaired and therefore unable to reliably report the missed doses or their effects.