Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents were involved in misappropriation findings. One resident with major depressive disorder, HF, and DM had a resident fund account with direct deposit income, a monthly allowance, and Medicaid patient liability issues tied to MITS and county income reporting. Another resident with COPD, oxygen dependence, and HF reported giving a former AA his bank card for purchases, and the state investigation found the AA misappropriated the resident’s property through fraudulent bankcard purchases.
Misappropriation of Resident Funds: A resident with dementia was not protected from alleged misappropriation of property when an LVN reportedly withdrew money from the resident’s bank account without consent. The resident said his bank card went missing from his drawer, a staff member helped him go to the bank, and he learned of unauthorized withdrawals linked to the LVN’s name on the bank statement.
Misappropriation of controlled medications occurred when staff could not account for missing oxycodone for several residents and liquid hydromorphone for another resident. One resident was severely cognitively impaired and others were cognitively intact or moderately impaired, with orders for scheduled opioid pain meds. Pharmacy records, MARs, and narcotic counts showed missing tablets, incomplete documentation, and a liquid opioid that appeared to have been replaced with water.
Unaccounted Resident Oxycodone: The facility failed to ensure a resident’s Oxycodone was properly accounted for after the pharmacy delivered 30 tablets for pain management. An LPN reported receiving the medication, placing it on a dresser at another LPN’s direction, and signing the controlled substance tracker as if it had been handed off, but the tracker did not document the Oxycodone and the facility could not account for the missing medication.
A resident with severe cognitive impairment and dependence for most ADLs had his debit card taken and used for $1,103.11 in unauthorized purchases. A friend who helped manage his bills discovered the account was overdrawn and found multiple disputed transactions, including charges at local stores and the facility vending machines. Police later arrested a CNA at the facility and found the resident’s debit card and SS card on him; the resident could not explain what happened.
Misappropriation of resident property occurred when a CNA was believed to have taken a resident’s debit card and made unauthorized purchases, and also took another resident’s debit card and cash. One resident had Alzheimer’s disease and the other was cognitively intact; both reported missing cards and unauthorized charges were confirmed through bank records, police review, and security footage, with the CNA admitting to taking the card and money.
Misappropriation of Resident Funds and Personal Property
Penalty
Summary
The facility failed to ensure Resident #61 was free from misappropriation of resident funds. Resident #61 was admitted with diagnoses including major depressive disorder, heart failure, and diabetes mellitus, and was documented as alert and oriented with a BIMS score of 13/15. The resident had a resident fund management services account with direct deposit of Social Security and pension income, a monthly allowance of $75.00, and a Medicaid patient liability of $672.00. Review of the resident fund records showed a current balance of $34,245.19 and quarterly statements showing repeated deposits and automatic withdrawals tied to care costs and patient liability. Facility staff stated the resident’s account was high because the county Medicaid Benefits Center did not receive the resident’s income information correctly, and the Medicaid supervisor stated the facility did not have the right to adjust the patient liability submitted in MITS. The facility also failed to ensure Resident #117 was free from misappropriation of personal property. Resident #117 was admitted with diagnoses including COPD, dependence on supplemental oxygen, and heart failure, and was documented as alert, oriented, and able to make decisions with intact cognition. The resident reported that he had used an outside bank account regularly and that he sometimes gave money or his bank card to a former activity aide to make purchases for him. The resident stated that on one occasion the debit card was given to the aide to purchase items for him and to assist with his Medicaid spend-down. The investigation and state findings identified that the former activity aide had misappropriated the resident’s property by making fraudulent purchases with the resident’s bank card. The employee file showed the aide had previously been terminated for unauthorized possession or use of property belonging to the facility. The ODH investigation record and letter stated that the allegation had a reasonable basis and that the Director adopted the finding of misappropriation against the aide. The facility’s abuse prohibition policy stated residents had the right to be free from abuse and misappropriation of resident property and/or funds.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when an LVN allegedly withdrew money from the resident’s bank account without the resident’s knowledge or permission. The resident had been admitted on December 16, 2025, and had a diagnosis of dementia. During the investigation, the Assistant Administrator stated she reported the allegation to police and was present when police interviewed the resident about the missing funds. According to the Assistant Administrator, the resident said he had gone to the bank with the facility’s BA after noticing his account balance was lower than expected, and the bank informed him of several unauthorized withdrawals. The resident filed a fraud report with the bank, and the bank statement reportedly showed the LVN’s name associated with the withdrawals. The resident later stated his bank card had been in his drawer and then went missing, and that a staff person helped him go to the bank to check his money, where he learned someone had taken a large amount of it. The facility’s Resident Rights policy stated residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation.
Misappropriation of Controlled Medications
Penalty
Summary
Facility staff failed to protect residents from misappropriation of controlled medications, including oxycodone and liquid hydromorphone, for four residents. The report states that Resident #12 had diagnoses including rheumatoid arthritis, contracture of the right shoulder, and hemiplegia/hemiparesis following cerebral infarction, and was severely cognitively impaired with a BIMS score of 3. The resident had an order for oxycodone 5 mg every 8 hours for pain, but review of narcotic control sheets and pharmacy delivery information showed multiple missing tablets that could not be accounted for, with no control sheets available for several date ranges and no destruction documentation located. Resident #44, who was cognitively intact with a BIMS score of 13 and had diagnoses including osteoarthritis of the knee and polyneuropathy, also had an order for oxycodone 5 mg twice daily for pain. The MAR showed doses documented as held, and pharmacy personnel confirmed that 60 tablets had been sent on one delivery and 30 tablets on another, leaving 30 tablets unaccounted for. The facility was unable to account for the missing oxycodone tablets. Resident #90, who had chronic pain and a BIMS score of 15, had an order for oxycodone 5 mg every 6 hours for pain/discomfort. Review of the narcotic sheets and eMAR showed doses that were not documented or accounted for, including discrepancies between the number of doses recorded on the control sheet and the number shown on the eMAR. The facility investigation identified a staff nurse as the alleged perpetrator in the missing controlled substances investigation involving Residents #90 and #91, and the nurse refused a drug screen and later terminated employment. Resident #91 had moderate cognitive impairment with a BIMS score of 7 and was ordered hydromorphone oral liquid 1 mg/mL every 4 hours for pain. The MAR showed two doses not administered before the resident’s death, and during the facility’s narcotic audit the liquid hydromorphone was found to have an abnormal color and consistency and was verified by the pharmacist to appear to have been replaced with water. The facility also reported a narcotic discrepancy during shift-change count and reviewed controlled substance records that required separate narcotic sheets and end-of-shift counts, but the medication was found altered and not properly accounted for.
Unaccounted Resident Oxycodone
Penalty
Summary
The facility failed to ensure misappropriation of resident property did not occur for one resident. Resident C had a diagnosis that included chronic pain syndrome. On 6/16/26, the pharmacy delivered 30 tablets of Oxycodone 15 mg for Resident C, and the medication was signed for by an LPN who no longer worked at the facility. An incident report later indicated that one card of Oxycodone was found to be unaccounted for. The written interview statement indicated the LPN who received the medications reported opening the pharmacy bag, signing the manifest, and delivering the medication to another LPN who was in a room with a resident. The first LPN stated she placed the medications on the dresser at the direction of the second LPN and then signed the controlled substance inventory tracker as having given the medications to that LPN. The June 2026 controlled substance inventory tracker did not document Resident C's Oxycodone, and the facility could not account for the missing medication.
CNA Took Resident’s Debit Card and Made Unauthorized Purchases
Penalty
Summary
The facility failed to ensure the right of a resident to be free from misappropriation of property when CNA A took the resident’s debit card and used it to spend $1,103.11 between late June and mid-July 2026. The resident’s record showed altered mental status, cirrhosis of the liver, spinal stenosis, and severe cognitive impairment with a BIMS score of 05. He was dependent on staff for toileting, bathing, dressing, and transfers, and required substantial assistance with eating, oral hygiene, personal hygiene, and rolling left and right. A police report stated that the resident was the victim of fraud involving his debit card. Friend A, who helped the resident with bills, reported that the resident’s account was in the negative after unauthorized transactions were discovered. Friend A stated that a staff member had assisted the resident with a phone bill and then kept the debit card, which was later used for multiple local purchases, including transactions at dollar stores, a liquor store, and the facility vending machines. Screenshots reviewed by surveyors showed 50 disputed transactions totaling $1,103.11. During interviews, the resident could not describe what happened to his debit card and could not identify who may have helped him with his bills. The HR Director stated that CNA A was arrested at the facility and that police found the resident’s debit card and social security card on CNA A’s person. The Administrator stated that the police were notified after Friend A discovered the unauthorized charges and that the facility had no reason to suspect CNA A had taken the card. The facility policy stated that staff must not permit misappropriation of resident property.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money, with theft occurring for 2 of 3 residents reviewed for misappropriation. Resident R4 had diagnoses including Alzheimer’s disease, heart failure, and cirrhosis of the liver, and his MDS documented him as cognitively intact. His care plan identified impaired cognitive function/dementia or impaired thought processes, and an intervention was later added noting he was offered a lock box for cards and money and educated on resident trust accounts. R4’s bank records documented two unauthorized debit card transactions totaling $44.68, and the investigation determined the claims were valid. R4 stated he could not find his debit card and thought he had it at the snack machine the day before; a room search with his approval did not locate the card. The guardian was notified, activity on the card was checked, and it was believed V26, a CNA, took R4’s card and made purchases. R4 later stated his son had full control over his finances and care and had told him there were unauthorized charges on the card. Resident R5 had diagnoses including chronic respiratory failure, type 2 diabetes mellitus, and hypertension, and her state report documented her as cognitively intact. Her state report also documented that police obtained security footage showing V26 using R5’s debit card to make purchases, and it was believed the same staff member took her cash as well. The police spoke with V26, who admitted taking the card and money. R5 stated her card had been stolen, that she reported it missing to a CNA, and that unauthorized charges were later found; she also stated the facility paid her back.
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