F0607

L

Failure to Implement and Follow Policies for Controlled Narcotic Accountability and Misappropriation Reporting

Wewoka, Oklahoma Survey Completed on 03-05-2026

Penalty

Fine: $130,240

Summary

The deficiency involves the facility’s failure to implement and follow policies and procedures to prevent and report misappropriation of a resident’s controlled narcotic medications. The facility had an undated Abuse Policy and Procedure stating residents have the right to be free from misappropriation of property and that the administrator would immediately report allegations to the Oklahoma State Department of Health and local police and conduct an immediate investigation. Resident #6 was admitted with diagnoses including chronic pain, hypertension, and major depressive disorder and had a physician’s order for oxycodone/APAP 10-325 mg, one tablet every six hours as needed, which was later discontinued. Pharmacy records showed 120 oxycodone/APAP tablets were delivered for this resident, but facility documentation only accounted for 30 tablets on the controlled drug count sheet, and the Medication Log of Receiving did not log the 12/15/25 delivery at all. The MARs for December and January showed only three documented doses, while the controlled drug count sheet reflected an additional 19 administered doses not documented on the MAR.

Staff interviews revealed multiple failures to act on and report suspected misappropriation and documentation irregularities. CMA #1 reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident did not request or take the medication beyond the first dose, and that they informed the administrator and were told it would be taken care of. Another CMA stated the issue was discovered during a cart count and that CMA #1 immediately reported it to the administrator. An anonymous staff member also stated they witnessed CMA #1 report the forged signatures to the administrator and ADON. However, the administrator later stated they were never informed of the issue and confirmed that neither the state agency nor law enforcement had been notified. LPN #1 acknowledged being told about the narcotic count sheet issue but did not follow up, believing it was the DON’s responsibility. The ADON stated they only ensured the count sheet and card matched before locking medications in the DON’s office and indicated RNs were usually responsible for reconciliation. The administrator stated reconciliation of the count sheet with the MAR should be done by the RN or charge nurse. LPN #2 denied administering any narcotics to the resident or signing the count sheet. Pharmacy staff confirmed that 120 tablets had been delivered, underscoring the discrepancy between delivered, documented, and administered doses and the facility’s failure to implement its own policies for reporting and investigating misappropriation of controlled medications.