Failure to Safeguard and Account for Controlled Pain Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to monitor and prevent misappropriation of a resident’s property, specifically controlled pain medication. Record review showed that a resident, in the facility since 2023, had an order dated 2/3/25 for oxycodone 5 mg four times daily for chronic back pain. On 10/27/25, an LPN (staff #24) signed a pharmacy packing slip at 9:16 PM confirming receipt of 30 tablets of oxycodone 5 mg for this resident. However, on 10/31/25, an RN (staff #25) discovered that all 30 oxycodone tablets and the administration record sheet for the resident were missing, and the facility was unable to locate the medications. Further review of the resident’s medication administration record and progress notes for November 2025 showed that the resident did not receive scheduled oxycodone doses on multiple occasions due to medication unavailability. Specifically, the resident did not receive the ordered 5 mg oxycodone doses on 11/1/25 at 12:00 AM and 6:00 AM, and on 11/2/25 at 12:00 AM and 6:00 AM, with progress notes documenting missed doses on 11/1/25 at 12:00 AM and 6:00 AM, and 11/2/25 at 12:00 AM because the medication was not available. During an interview, the acting DON reported that staff #24 continued to deny opening the plastic bag containing the drugs, but the missing controlled medications and associated documentation could not be accounted for, resulting in the resident not receiving ordered pain medication for chronic back pain during the documented times.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.