F0602

E

Misappropriation and Poor Control of Controlled Medications for Multiple Residents

Longview, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of medications and to follow its own drug discrepancy and diversion policy. For one cognitively intact female resident with osteomyelitis, diabetes, malnutrition, and trauma-related pain, Hydrocodone-Acetaminophen (Norco) tablets were missing from her narcotic supply. An LPN reported that the narcotic count showed 18 Norco tablets the previous night but only 17 in the bottle the next morning, while the narcotic count sheet reflected that a dose had been administered at 9:00 p.m. even though the medication was not documented as given in the electronic MAR. The resident stated there was a night when she fell asleep and was not awakened for medications and did not receive her pain medication, although she otherwise reported receiving medications when requested. The LPN also observed that the nurse from the prior shift appeared "off" and was falling asleep during narcotic counts but did not notify the administrator, only the weekend supervisor.

A male resident with a history of cerebral infarction, spinal stenosis, subarachnoid hemorrhage, and diabetes, who received scheduled and PRN pain medications including Gabapentin and Acetaminophen-Codeine (Tylenol #3), was also affected by narcotic discrepancies. An LPN reported that after new medication cards for Tylenol #3 and Lyrica were delivered, she returned the next morning to find one Tylenol #3 card with four tablets missing and two Tylenol #3 tablets left in a medication cup on the cart. She stated that the same LPN who had appeared impaired during narcotic counts was falling asleep and seemed odd, and that she herself was later drug tested and disclosed her own prescribed Tylenol #3 use. A CNA reported that this LPN moved fast, had difficulty with motor skills, left resident rooms messy, did not promptly respond to residents’ requests for pain medication, and told residents she would get there when she could. The CNA stated she reported these concerns to another nurse. The DON later acknowledged receiving reports that the nurse appeared impaired, including tripping over herself and wasting a tube feeding in a resident’s bed, and that there was a delay in these concerns being reported.

Two additional residents experienced issues related to missing or potentially undelivered controlled medications. A cognitively intact female resident with COPD, UTI, overactive bladder, diabetes, and polyneuropathy, who was on scheduled Hydrocodone-Acetaminophen for chronic pain, reported that on a couple of occasions she was told the facility had not received her pain medications, though she did not specify dates and stated the medications were effective when received. Another resident with Parkinsonism, polyneuropathy, muscle wasting, and diabetes, who took Pregabalin for pain, reported that her pain medication was effective but that there were delays in receiving medications at times and that she had to ask for pain medications because they were not scheduled. The DON and ADON described that, during the period when medications for these residents went missing, the facility had changed pharmacies, did not initially have packing slips, and nurses would sign for bags of medications without verifying contents. Staff interviews indicated uncertainty about whether certain narcotic medications for these residents were ever actually received, inconsistent handling of delivered medications (including hospice narcotics left in a box for weeks), delays of up to two weeks before staff were drug tested after medications were reported missing, and lack of in-service training on drug diversion and abuse/neglect for some staff. The facility’s own policy required immediate notification of administration and pharmacy, prompt investigation, reconciliation, and notification of appropriate agencies for any discrepancies or suspected diversion, but staff accounts showed delays in reporting, incomplete documentation, and inconsistent implementation of these procedures.

Across these events, multiple nurses and CNAs described the same LPN as appearing impaired, falling asleep during narcotic counts, and failing to respond promptly to residents’ pain complaints, while narcotic counts for Hydrocodone, Acetaminophen-Codeine, and Pregabalin were found to be off or medications were reported as not received. The DON stated that she expected nurses not to accept a medication cart with unresolved narcotic discrepancies and to report impaired staff immediately, but interviews revealed that counts were sometimes accepted despite discrepancies, that concerns about impairment were reported late, and that the DON did not come to the facility on the day of the diversion because supervisors were present. The DON and ADON also acknowledged that, prior to implementation of a new process, there was no clear protocol with the new pharmacy for verifying receipt of medications, packing slips were not used, and it was unclear whether some missing medications for the affected residents had ever been delivered. These combined actions and inactions resulted in misappropriation or unexplained loss of controlled medications for four residents and failure to ensure that physician-ordered medications were consistently available and properly safeguarded.