WEST POINT, MS - A nursing home in West Point allowed a licensed practical nurse to continue working with controlled substances after 30 tablets of hydrocodone went missing under her supervision, according to a recent federal inspection that documented serious medication security violations.
Controlled Substance Security Breach
West Point Community Living Center experienced a significant medication security failure on February 18, 2025, when a 30-count card of hydrocodone prescribed for a resident disappeared from the facility's medication cart. The incident exposed multiple breakdowns in the nursing home's drug security protocols and raised questions about patient safety oversight.
Licensed Practical Nurse #1 was responsible for the medication cart when the controlled substances went missing. During interviews with federal inspectors, she acknowledged leaving medication cart keys unattended on a desk while she went outside and also leaving keys accessible on the cart while a corporate nurse conducted an inspection. The missing medication was discovered between 2:30 PM and 3:00 PM that afternoon.
The hydrocodone tablets have never been recovered, according to facility administrators. Police were contacted the following day and responded to investigate the missing narcotics, conducting a drug test on the nurse involved before allowing her to return to her duties.
Continued Access Despite Investigation
Federal regulations require nursing homes to immediately remove employees accused of resident abuse or misappropriation from direct resident contact during investigations. However, West Point Community Living Center's own policies clearly state that any employee accused of resident abuse should be "placed on leave with no resident contact until the investigation is complete."
Despite these requirements and the facility's written protocols, LPN #1 continued working her full shift after the medication was discovered missing. She completed medication administration duties for residents throughout the afternoon and evening, including the evening medication pass, before clocking out at 11:36 PM - more than eight hours after the theft was reported.
The facility's administrator confirmed during the inspection that the nurse was not required to turn in her keys or leave the facility during the investigation. This decision directly violated both federal regulations and the nursing home's own established policies for handling suspected misappropriation incidents.
Medical Implications of Controlled Substance Theft
Hydrocodone is a Schedule II controlled substance classified as an opioid pain medication. When prescribed medications go missing in healthcare facilities, it creates multiple risks for patient care and safety. Residents who depend on these medications for pain management may face inadequate treatment if replacement medications are not immediately available.
The theft of controlled substances also indicates potential security vulnerabilities that could affect other medications and resident property. Opioid medications have significant abuse potential and street value, making them frequent targets for diversion in healthcare settings.
Proper medication security protocols exist specifically to prevent unauthorized access to controlled substances. These include requirements for locked storage, key control procedures, and immediate removal of suspected individuals from medication-handling duties. When these safeguards fail, it compromises the entire medication management system.
Policy Violations and Regulatory Requirements
The facility's own controlled substance policy requires that "controlled substances are separately locked in permanently affixed compartments" and that "all keys to controlled substance containers are on a single key ring that is different from any other keys." The charge nurse on duty should maintain these keys at all times, with backup keys held only by the director of nursing services.
Federal regulations under 42 CFR 483.12 mandate that nursing homes must immediately investigate any allegations of misappropriation and ensure that alleged perpetrators have no access to residents or their property during investigations. This protection extends beyond physical safety to include financial security and personal belongings.
The facility's failure to follow its own written procedures demonstrates a breakdown in institutional oversight. Time card records showed LPN #1 worked from 6:37 AM to 11:36 PM on February 18, continuing to sign controlled drug count records as accurate throughout her extended shift, even after the missing medication was discovered.
Inadequate Investigation Response
Standard healthcare industry practices require immediate action when controlled substances are reported missing. This typically includes securing the medication area, documenting the incident, notifying appropriate authorities, and removing the responsible individual from medication-handling duties pending investigation completion.
West Point Community Living Center's response fell short of these standards. While police were contacted and a drug test was administered, allowing the nurse to continue working with controlled substances created ongoing risk for additional theft or diversion. The facility essentially permitted continued access to the very type of medication that had already been compromised.
The controlled drugs count record for February 2025 shows LPN #1 signed off on narcotic medication inventories as correct at multiple points throughout February 18, including after the theft was discovered. This documentation suggests either inadequate inventory procedures or failure to properly investigate the scope of potentially missing medications.
Additional Issues Identified
The inspection revealed other concerning practices related to medication security and staff oversight. The facility's handling of the incident demonstrated insufficient understanding of federal requirements for protecting residents from potential misappropriation.
Documentation gaps in the investigation process raised questions about the thoroughness of internal reviews. The extended delay between the theft discovery and police notification - occurring the following day rather than immediately - suggests inadequate emergency response procedures for controlled substance incidents.
The facility's decision-making process for determining whether to remove staff members during investigations appears to lack clear criteria or consistent application of established policies.
Federal inspectors classified these violations as causing minimal harm with potential for actual harm, affecting few residents. However, the regulatory failures identified represent systemic issues that could impact medication security for all residents requiring controlled substances for pain management and other medical conditions.
The incident highlights the critical importance of strict adherence to controlled substance protocols in long-term care facilities, where vulnerable residents depend on staff to properly safeguard their medications and protect them from potential exploitation or abuse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Point Community Living Center from 2025-04-08 including all violations, facility responses, and corrective action plans.
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