F0607

D

Failure to Report Alleged Narcotic Diversion to State Survey Agency

Glasgow, Kentucky Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The facility failed to implement its written policy to ensure abuse allegations were reported to the State Survey Agency (SSA) as required by Federal and State law for one resident. The facility’s policy, revised 02/01/2023, required that any patient event reported be considered an allegation of abuse, neglect, misappropriation of property, or exploitation, and that all alleged violations be reported immediately, or within 24 hours if not involving abuse with serious bodily injury, to the Administrator. The policy further required that all alleged violations be reported to other officials, including the SSA, in accordance with State law and Federal regulations. Despite this, the incident involving a concern about possible narcotic diversion for one resident was not reported to the SSA.

The resident involved was admitted with a fracture of the head of the right femur, dementia, and anxiety disorder, and had a BIMS score of 6/15, indicating severe cognitive impairment. On 11/04/2025, the Station 3 Unit Manager reported to the DON a concern that an RN had wasted a narcotic medication for this resident, witnessed by an LPN, in a manner inconsistent with the resident’s known practice of taking pills whole; the wasted medication was described as a spilled crushed medication. The DON notified the Administrator of the concern on 11/05/2025. On 11/10/2025, the DON was informed by a Regional Nurse that an anonymous call had been made to the company’s Values Line regarding the RN and narcotics, prompting an internal investigation involving the DON, ADON, RN, and Administrator.

Further review showed that on three consecutive days later in November, the RN documented administering six doses of the resident’s oxycodone-acetaminophen 5-325 mg, leading to notification of the Medical Director and an order for a drug screen for the resident. Interviews revealed that Regional Nurse 1 considered reporting to be “extremely situational” and stated that the incident did not meet misappropriation criteria and therefore was not reported to the SSA, though it was reported to the state nursing board. The DON stated she believed the situation had been handled correctly and did not view the concern as a reasonable suspicion until a negative drug screen result was obtained, characterizing it as one nurse complaining about another. The Administrator stated she believed there had been no abuse and that the only required reporting was to the nursing board, demonstrating that the facility did not follow its own policy requiring reporting of all alleged violations to the SSA.