F0602

D

Misappropriation of Resident Medications and Failure to Safeguard Controlled Substances

Warren, Ohio Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of medications and to ensure medications were administered only as ordered. For one resident with Alzheimer’s disease, malnutrition, anxiety, and other conditions, the quarterly MDS showed cognitive impairment and a need for supervision with eating and staff assistance for all ADLs, including medication administration. On an evening in August, an LPN obtained a vial of Haldol 5 mg IM from another resident’s stock supply without a physician’s order for this resident and administered an injection in the resident’s room. Multiple CNAs reported being asked to assist the resident to the room, witnessed the LPN pull down the resident’s pants and give the injection, and stated the LPN told them not to say anything because the medication was not prescribed for the resident and had been taken from another resident’s supply. The DON confirmed there was no Haldol order for this resident on that date, that a vial was missing from the other resident’s Haldol supply, and that the LPN denied giving the dose.

A second deficiency involved misappropriation and inaccurate handling of a controlled substance prescribed for another resident with ADHD, bipolar disorder, seizures, Tourette’s disorder, and other diagnoses. This resident was cognitively intact and independent with ADLs, and had an order for Adderall 20 mg twice daily at specific times. Review of the narcotic count sheets showed that on multiple occasions over two days, the Adderall pill count decreased by two tablets at times when only one tablet was ordered to be administered, all associated with the same LPN’s signatures. These discrepancies indicated that two pills were removed from the count when only one was ordered for the resident at each administration time. The DON later described that the LPN could not explain the discrepancies, claimed to have wasted a capsule without a witness, initially refused an in‑facility urine drug screen, delayed completion of an independent drug test, and that the facility’s policy stated refusal or failure to comply with drug testing requirements would be considered a refusal to test and subject to immediate termination.

A third deficiency involved another resident with intact cognition and independence in ADLs who had multiple medical diagnoses and an order for Oxycodone 5 mg, one tablet by mouth every four hours as needed for pain. The MAR documented that this resident received single 5 mg doses at several times over two days, all administered by an agency LPN. However, the narcotic count sheet for the same period showed that the agency LPN repeatedly signed out two tablets at each administration time, including multiple entries for the same early‑morning time, despite the order being for only one tablet as needed. A subsequent review of the narcotic count by another LPN revealed discrepancies between the MAR and the narcotic sheet, with repeated documentation of two tablets being removed when only one tablet was ordered and documented as given. The DON stated that misappropriation occurred in all three incidents and that the facility’s abuse, neglect, and exploitation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and that the facility had unsubstantiated these incidents despite the misappropriation having occurred.

The facility’s own policies and job descriptions further framed the deficiencies. The LPN job description required accurate preparation and administration of medications according to physician orders and accurate recording of medications administered. The Drug Free Safety Policy specified that refusal to comply with testing requirements, failure to provide valid specimens, or refusal to submit to reasonable suspicion or follow‑up tests would be considered a refusal to test and subject to immediate termination. The Abuse, Neglect, and Exploitation policy stated that the facility would implement policies and procedures to prevent and prohibit misappropriation of resident property. Despite these written expectations, the events described show that medications belonging to or prescribed for specific residents were wrongfully used or removed, and that in one case an LPN’s conduct around drug testing did not align with the facility’s stated policy, contributing to the overall deficiency in protecting residents from misappropriation.