WEST POINT, MS - Federal inspectors cited West Point Community Living Center after a licensed practical nurse left narcotic medication keys unattended, leading to the disappearance of a resident's controlled pain medication.
Missing Pain Medication Discovered
The incident occurred on April 8, 2025, when Licensed Practical Nurse #1 discovered that a 30-count card of Norco (hydrocodone) oral tablets prescribed for a resident had gone missing from the medication cart. The medication, containing hydrocodone and acetaminophen, was prescribed for severe pain management with dosing instructions of one tablet every six hours as needed.
According to the inspection report, the nurse had made what she described as a "careless mistake" earlier that day by leaving the narcotic medication keys unattended on the nurses' station desk while taking a break outside. The keys were also left unattended on the medication cart while a corporate nurse conducted routine checks for expired and unlabeled medications.
The missing medication was discovered around 2:30-3:00 PM when the nurse attempted to access the controlled substances box to retrieve pain medication for the affected resident. Despite immediate searches by facility staff, the medication card was never located.
Security Protocol Violations
Federal regulations require nursing facilities to maintain strict security protocols for controlled substances. The facility's own policy mandates that controlled substances must be separately locked in permanently affixed compartments, with all keys maintained on a single key ring different from other facility keys.
Most critically, the policy states that "the charge nurse on duty maintains the keys to controlled substance containers," implying these keys should remain in the nurse's physical possession at all times. The inspection revealed the nurse had violated this protocol twice in one day - first by leaving keys on the desk during a break, then by placing them on the medication cart during the corporate inspection.
The facility administrator acknowledged that medication keys "were to remain with the nurse on their person at all times to prevent an unauthorized person having access to the residents' medications." This security measure exists to protect both residents' prescribed medications and prevent potential diversion of controlled substances.
Medication Security and Patient Safety
Hydrocodone-containing medications like Norco are classified as Schedule II controlled substances under federal law due to their high potential for abuse and dependence. These medications require the highest level of security in healthcare facilities, with strict tracking and accountability measures.
When controlled substances go missing in healthcare settings, it creates multiple risks. The primary concern involves patients who depend on these medications for pain management potentially facing interruption in their prescribed treatment. Additionally, missing controlled substances pose diversion risks, where medications could be accessed by unauthorized individuals for non-medical purposes.
For residents in nursing facilities, consistent access to prescribed pain medications is particularly important. Many residents have complex medical conditions requiring carefully managed pain relief protocols. Disruption in medication availability can lead to increased discomfort and potential complications in their overall care management.
Investigation and Response
The facility initiated an immediate investigation following the discovery of the missing medication. All staff members who worked that day underwent drug screening tests and provided written statements about the incident. The nurse involved tested negative for drugs and acknowledged her policy violations in a written statement.
Despite the ongoing investigation into missing controlled substances, the facility allowed the nurse to continue working her scheduled shift, which extended from 7:00 AM to 11:00 PM. She completed her evening medication administration duties and returned to work after her scheduled days off without immediate suspension or restriction of duties.
Federal inspectors noted this as a significant failure in the facility's response protocol. The investigation found that the facility "failed to prevent further potential medication misappropriation by allowing a nurse to continue to work during an investigation."
Regulatory Standards and Expectations
Federal nursing home regulations establish clear expectations for protecting residents from abuse, neglect, and misappropriation of property. The misappropriation standard specifically addresses "deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent."
While the investigation did not determine intentional theft, the security failures created conditions that enabled the medication to go missing. The facility's own policies recognized the importance of continuous key security, stating that medication keys should remain under direct nurse supervision to prevent unauthorized access.
Industry best practices for controlled substance management include multiple verification steps, dual-key systems, and immediate incident reporting protocols. Many facilities implement additional security measures such as biometric locks, surveillance systems, and frequent medication counts to prevent similar incidents.
Affected Resident Profile
The resident whose medication went missing was admitted to the facility for complex medical conditions including a displaced midcervical fracture of the left femur, post-surgical joint replacement care, and dementia. Assessment records indicated the resident had moderate cognitive impairment, making them particularly vulnerable to medication access disruptions.
Residents with cognitive impairment require consistent medication administration protocols, as they may not be able to communicate effectively about pain levels or understand delays in medication availability. The combination of surgical recovery needs and cognitive challenges makes reliable pain medication access especially important for this resident population.
Facility Response and Corrections
The facility administrator confirmed reporting the incident to required regulatory entities as mandated by federal and state law. Such reporting requirements ensure oversight agencies can monitor patterns of medication security issues and take appropriate enforcement actions when necessary.
The inspection classified this violation as having "minimal harm or potential for actual harm" affecting "few" residents. However, the regulatory citation emphasizes the serious nature of controlled substance security breaches and the facility's responsibility to prevent medication misappropriation through proper protocols and staff supervision.
Moving forward, the facility must demonstrate improved medication security measures and staff training to prevent similar incidents. This includes ensuring all nursing staff understand and consistently follow controlled substance security protocols, particularly regarding key management and continuous supervision requirements.
The citation serves as a reminder that medication security in nursing facilities requires constant vigilance and adherence to established protocols to protect vulnerable residents and maintain regulatory compliance.
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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