Unaccounted Narcotics and Misappropriation of Resident Medications via I-STAT Withdrawals
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property when staff could not account for 19 missing controlled-substance tablets for 10 residents. Facility policies required controlled substances to be stored under double-lock conditions, counted every shift, and any discrepancies reported immediately to the DON. Policies also required that if a medication with an active order could not be located in the cart, staff should search other areas and, if still not found, obtain it from the I-STAT and document administration on the MAR. The abuse and misappropriation policy required investigation of suspected misappropriation and staff education on prevention and reporting responsibilities. The events leading to the deficiency centered on RN A’s repeated withdrawal of narcotics from the I-STAT automated dispensing cabinet without corresponding documentation of administration on the MAR or in the EHR. On one morning, after receiving shift report, RN B observed RN A in the medication room logging into the I-STAT and withdrawing an oxycodone 10 mg tablet under a resident’s name without a request from the CMT assigned to that hall. RN B then saw RN A coming from the bathroom, and RN A made a comment about feeling alive again. The resident under whose name the oxycodone was withdrawn could not recall exactly when they last received a pain pill and only remembered that a female had given it. Review of I-STAT records showed that on multiple prior occasions over several months, RN A had withdrawn oxycodone, hydrocodone-APAP, and tramadol tablets for various residents without any documentation of administration on the MAR. Ten residents with orders for PRN narcotic analgesics were involved. One resident with multiple sclerosis, COPD, atrial fibrillation, dementia, and frequent, constant pain had an order for oxycodone IR 10 mg every four hours PRN; I-STAT records showed several oxycodone tablets withdrawn by RN A on different dates with no corresponding MAR entries. Another resident with brain cancer, COPD, and diabetes had tramadol 50 mg PRN ordered, and a tramadol tablet was withdrawn by RN A without documentation. Additional residents with diagnoses including rhabdomyolysis, hip pain, Parkinson’s disease, Alzheimer’s disease, dementia, heart failure, atrial fibrillation, obesity, unspecified pain, encopresis, cachexia, stroke, and recent amputation had PRN orders for hydrocodone-APAP or tramadol; for each, I-STAT reports showed narcotic tablets removed by RN A on specific dates and times with no documentation of administration in the EHR or MAR. Staff interviews confirmed that narcotics were supposed to be double-locked, counted each shift, signed out on the narcotic log and MAR, and that missing narcotics were considered misappropriation. The consultant pharmacist explained that the I-STAT system tracks cabinet inventory but does not by itself confirm administration, so withdrawals that are not documented on the MAR would not create an automatic discrepancy in the I-STAT count. The DON stated awareness that RN A had a history of medication diversion and had instructed RN A not to administer narcotics, indicating that CMTs were to administer all medications. Despite this, it was later discovered that RN A had been pulling narcotics from the I-STAT. The DON had been running weekly discrepancy reports on the I-STAT and conducting monthly narcotic counts with the consultant pharmacist, but these processes did not detect RN A’s pattern because the I-STAT counts remained correct. Only when the DON ran a report by nurse name and compared each I-STAT withdrawal to the EHR MAR and narcotic log did it become evident that RN A had repeatedly removed narcotics without documented administration, resulting in 19 missing narcotic tablets for 10 residents and constituting misappropriation of resident medications. Interviews with CMTs and an RN confirmed that they performed narcotic counts with off-going staff each shift, maintained double-lock security, did not give their keys to others, and would notify the DON immediately of any discrepancy. They also stated that they signed out narcotics on both the narcotic log and MAR and that they considered missing narcotics to be misappropriation. The consultant pharmacist confirmed that medications were delivered daily and that the pharmacy ran a daily controlled-medication report, but that the I-STAT system alone would not flag missing doses if the cabinet count remained accurate. The Administrator stated that missing narcotics were considered misappropriation of property and that an investigation was initiated after being notified of potential diversion, ultimately revealing that RN A had been removing narcotics from the I-STAT and not administering them to residents. Overall, the facility failed to prevent misappropriation of resident medications by not detecting that RN A, who had a known history of diversion and had been instructed not to administer narcotics, was repeatedly withdrawing controlled substances from the I-STAT without documentation of administration. This resulted in 19 unaccounted-for narcotic tablets intended for 10 residents with documented pain and PRN orders for oxycodone, hydrocodone-APAP, or tramadol, in violation of the facility’s own policies on controlled substances, medication administration, and prevention of misappropriation of resident property.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cerebral infarction and cognitive communication deficit gave $280 to the Medical Records Manager after staff were asked to clean his apartment before discharge. Although the Administrator said the facility would pay staff and the resident would have no out-of-pocket expense, the Medical Records Manager accepted the money, placed it in her work bag, and did not refuse it at the time. Transportation staff reported seeing the exchange, and the DON later confirmed the funds had been returned to the resident.
An RN diverted controlled medications belonging to two residents, including pain meds ordered for a resident with dementia and a resident with multiple fractures and cognitive deficits. The RN was stopped by police after leaving work and was found with facility medications in the residents’ names. The DON stated that prior narcotic counts relied on matching log sheets and counting individual contents, and staff did not detect the missing meds because the corresponding narcotic logs were also absent.
Misappropriation of Resident Property: A resident with multiple chronic conditions and mild cognitive impairment had a debit card stolen and used without authorization by a facility employee. The resident’s daughter reported the missing card, the Administrator confirmed the unauthorized charge, and police later identified the employee using the card and arrested her.
An LPN documented PRN pain meds as given to multiple residents, but residents said they had not requested or received them. For one resident, pain assessments and blood levels were inconsistent with the MAR entries, and similar concerns were identified for several other residents involving controlled PRN meds.
A resident with moderate cognitive impairment and chronic pain had an oxycodone/APAP order with two 30-count cards received. Staff accounts showed the narcotic count sheet was altered, signatures were written on it, and the original paperwork was discarded. One CMA said she destroyed the wrong medication after believing it was discontinued and admitted she did not complete the required checks or have a second staff member present. The medication, card, and count sheet were never found after searches of the cart, trash, shred bins, and dumpster.
An employee admitted to taking money from petty cash and the Resident Trust cash box, and an audit confirmed shortages in both accounts. The employee self-reported the theft, and the record review documented the missing funds and the discrepancy between the ledger totals and the cash on hand.
Misappropriation of Resident Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal funds when the Medical Records Manager accepted $280 from Resident #60 for cleaning his personal apartment. The facility’s policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent, and the facility’s code of ethics prohibited accepting gifts or gratuities from a patient or family member. Resident #60 was admitted with diagnoses including cerebral infarction and cognitive communication deficit, and a quarterly MDS dated 3/11/26 indicated he was cognitively intact. The Administrator had asked the Activities Director and the former Medical Records Manager to clean the resident’s apartment before discharge, and the Administrator stated the facility would pay them so the resident would have no out-of-pocket expense. Despite this, the resident was later taken to the Medical Records Manager’s home while transportation staff were involved in moving him between locations related to his apartment and rent arrangements. Multiple staff accounts described the resident handing money to the Medical Records Manager at her home on 4/17/26. The Transportation Assistant stated she saw the resident reach into his pocket and give the Medical Records Manager money, and the Transportation Director stated the resident told him the money was because they were supposed to paint his apartment. The Medical Records Manager stated she accepted the money, put it in her work bag, and did not return it at the time. The DON stated the Medical Records Manager later returned $280 to the facility, and the money was counted back to the resident with a signed receipt. The facility’s investigation concluded the Medical Records Manager had accepted money from the resident, and the report identified this as the deficient practice.
Controlled medications from two residents were diverted by an RN
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money when a staff RN diverted controlled medications belonging to two residents. Resident 68 was admitted with diagnoses including a right humerus fracture, pneumonia, and dementia, and had orders for Pregabalin and oxyCODONE for pain. Resident 73 was admitted with diagnoses including multiple left rib fractures, a left clavicle fracture, a history of traumatic brain injury, and cognitive communication deficit, and had an order for oxyCODONE-acetaminophen for pain. On 1/15/26, the State Survey Agency received a facility-reported incident stating that an RN was stopped by police after leaving work and was found in possession of medications from the facility in the names of the two residents. The facility stated the medications were returned and that the residents did not miss doses. The incident involved Resident 68’s Pregabalin and oxyCODONE and Resident 73’s oxyCODONE, which had been removed from the facility while the RN was working the night shift. The DON stated that prior to the incident, narcotic counts were based on reconciling the narcotic log sheet and manually counting individual contents in blister cards or patches, but the total units of narcotics in the cart were not manually counted. The DON also stated that discontinued narcotics were kept in the medication cart until collected for destruction, and staff did not notice the missing medications for Residents 68 and 73 during shift change counts because the corresponding narcotic log sheets were also absent.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when the resident’s bank card was stolen and used without authorization by a facility staff member. The resident, who was admitted with diagnoses including diabetes mellitus, C. difficile enterocolitis, congestive heart failure, hyperlipidemia, ischemic cardiomyopathy, muscle wasting, hypertension, and GERD, also had mild cognitive impairment per the MDS. The resident was discharged from the facility on 3/7/26. The facility’s incident report documented that the resident’s daughter reported the debit card was missing, and the Administrator later stated that the daughter reported unauthorized use of the card. The Administrator said the card was used for a one-time $30 charge, and the incident had already been reported to police. The Administrator further stated that police later came to the facility and showed images of an employee using the resident’s card without authorization, and the employee was arrested on the spot. The facility’s Abuse Prevention and Reporting policy stated its purpose was to prevent abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents.
PRN Medications Documented as Given but Not Actually Administered
Penalty
Summary
The facility failed to ensure the safety and security of resident property, specifically PRN medication, after it was discovered that an LPN was not actually giving PRN medications to assigned residents even though the medications were being documented as administered on the MAR. During the survey process, residents were asked about their PRN medication needs and use, and multiple residents stated they had not requested those medications despite the charting showing they had been given. This led the facility to investigate whether diversion was occurring. For Resident #64, the facility reviewed the MAR and pain assessments and found that the resident’s daily pain was generally documented as zero to one out of ten, while the PRN pain scale entries on the days in question showed pain levels of five to seven out of ten before medication administration and zero out of ten afterward. The facility also obtained blood work with the resident’s permission, which showed only trace amounts of pain medication in the resident’s system, inconsistent with the documented administrations. Similar concerns were identified for other residents, including Residents #1, #15, #39, #56, and #65, involving controlled PRN pain medications.
Missing Narcotic Medication and Altered Count Record
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a prescribed narcotic medication became missing from the facility. Resident #6 had moderate cognitive impairment with a BIMS score of 12 and diagnoses including intervertebral disk degeneration with lumbar and lower extremity pain. The resident had an order for oxycodone/acetaminophen 10/325 mg, 1 tablet by mouth twice daily, and the MAR and narcotic record showed two separate 30-count medication cards were received for the resident. The narcotic record and staff interviews showed that the medication count became inconsistent after the medication cards were handled on the medication cart. One staff member stated she received two narcotic cards for the resident and counted 60 tablets total with another nurse at shift change. Another staff member later stated she found the count sheet incorrect and reported that the count was off by a whole card of 30 tablets. The staff accounts also showed that the count sheet had been altered, with signatures written on it and the original paperwork no longer available. Staff interviews further showed that one CMA stated she destroyed the wrong narcotic medication after believing it had been discontinued in the EHR, and she admitted she did not complete the required checks before destroying it. She stated she removed the tablets, discarded the bubble pack in the medication cart trash, and placed the top of the medication card in the shred bin. Other staff stated narcotic destruction required two nursing staff present, but the medication and related paperwork for the resident were not found after searches of the carts, trash, shred bins, and dumpster. The Administrator stated the resident’s oxycodone/acetaminophen prescription had to be replaced because the medication was never found and had been removed from the facility.
Misappropriation of Resident Funds by Employee
Penalty
Summary
The facility failed to protect resident funds from misappropriation when an employee admitted to taking $40.00 from petty cash and $240.00 from the Resident Trust cash. The incident occurred when the employee called to self-report that she had borrowed the money from both accounts. A statement from the employee confirmed the taking of the funds, and an audit of the financial records showed discrepancies in both the petty cash and Resident Trust cash box balances. The record review showed the petty cash General Ledger total was $200.00 while the actual cash counted was $159.65, with a cash withdrawal of $40.35 noted. The Resident Trust Cash Box General Ledger total was $250.00 while the actual cash counted was $10.00, with a cash withdrawal of $240.00 noted. The corporate Senior Financial Analyst later reviewed the accounts and found no additional missing funds. The report also states that the employee was terminated and a police report was filed after the theft was reported.
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