F0609

D

Failure to Report Drug Diversion to Adult Protective Services

Oxford, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to report an allegation of misappropriation of resident property to Adult Protective Services (APS) as required by its own abuse, neglect, and misappropriation policy. The policy, last revised 12/12/25, stated that residents have the right to be free from abuse, including misappropriation of property, and defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. The policy required immediate reporting, but no later than 2 hours for allegations involving abuse or serious injury, and no later than 24 hours for other allegations, to specified agencies including the State Survey Agency and APS. The Administrator or designee was responsible for ensuring all required agencies were notified.

Record review showed that on 4/1/25 at 2:00 PM the facility became aware of a discrepancy involving a resident's liquid morphine, and an audit that same day identified missing narcotics. An investigation was initiated, and a nurse was identified as the suspected staff member and suspended pending investigation. The investigation, completed on 4/9/25, substantiated diversion of the resident's medication and identified the nurse as responsible, with 3.75 mL of morphine sulfate determined to be missing. The facility notified law enforcement, the Drug Enforcement Agency, the State Agency, and the Board of Nursing; however, the Investigation Report indicated APS/Department of Social Services were not notified. In interview, the Administrator acknowledged that the discrepancy was initially thought to be a calculation error, that the resident was under hospice care and did not experience treatment interruption, and that she missed reporting the diversion of a resident drug to APS.