The controlled substance disappeared on August 22, 2025, when Staff D, a licensed practical nurse, handed off medications to another nurse without following the facility's documentation requirements for narcotic transfers.
Staff D had signed for the lorazepam delivery that evening — a full bottle of sixty 0.5-milligram anxiety pills for Resident #2, who has diagnoses of anxiety disorder, schizophrenia, and hallucinations. The packing slip showed Staff D acknowledged receipt of the medication by signing below a statement that read "by signing below, you acknowledge that the items above have been received."
But Staff D gave the medications to the Assistant Director of Nursing, thinking the resident had moved to her hall. The ADON then passed them to Staff E, the actual nurse for that resident's unit.
Staff E received the handoff about ten minutes into her shift. She got two medications for Resident #2, but none were narcotics. She placed what she received into the medication cart and never got any narcotic documentation sheets.
The missing pills weren't discovered until the next day.
Staff F, a registered nurse, tried to reorder the lorazepam on August 23 because only two pills remained in the facility's supply. The pharmacy faxed back that they had sent an entire bottle the previous day.
"She stated they searched every drawer of every cart but couldn't locate the medication," the inspection report documented.
The pharmacy delivery records showed sixty pills had been sent. Staff D had signed for them. But somewhere between the loading dock and the locked medication compartment, an entire bottle of controlled substances had disappeared.
Staff D told inspectors she had checked in all medications individually that night, then gave Resident #2's medications to the ADON because she thought the resident had moved halls. The ADON gave them to Staff E, who was actually the resident's assigned nurse.
"Staff D stated they didn't have documentation she gave the medication to the ADON," inspectors wrote.
The ADON's account differed slightly. She said Staff D accidentally gave her medications meant for a different hall. She gave them back to Staff D, then Staff E placed the medications in the correct cart. But she reported the medications as clozapine, a sedative that isn't a controlled substance, and said she didn't think the lorazepam came in that delivery.
The facility's controlled substances policy, updated in October 2022, required specific documentation when nurses received controlled medications. They needed to fill out the top of the controlled drug administration record and complete the first line counting the medications to indicate who signed them in from the pharmacy.
None of that happened.
The Director of Nursing admitted she didn't know what occurred with the missing medication. "She added that possibly the nurse was just nervous and accidentally checked the medication in," the inspection noted.
But the pharmacy records were clear — they had delivered sixty pills, and Staff D had signed for them.
Staff F had been putting narcotics directly into medication carts after checking them in, filling out a paper sheet with the quantity. The DON said nurses should place controlled substances in locked boxes themselves after checking them in.
The missing lorazepam was prescribed twice daily for Resident #2's anxiety. With only two pills remaining when Staff F tried to reorder, the resident faced potential medication interruption for a condition requiring consistent treatment.
Federal regulations require nursing homes to store controlled substances in separately locked compartments and maintain strict documentation of their handling. The regulations exist because controlled substances like lorazepam carry risks of abuse, diversion, and black market sale.
In response to the incident, the facility implemented a new policy requiring two nurses to sign when receiving narcotics. The DON also established that nurses must personally place controlled substances in locked storage rather than handing them to other staff.
But for the sixty lorazepam pills that disappeared on August 22, no documentation exists showing who ultimately had possession of them. Staff D signed for their receipt. Multiple nurses handled medications that shift. And by morning, an entire bottle of controlled anxiety medication had vanished without a trace.
The facility reported a census of 46 residents at the time of the October 2025 inspection. Resident #2 had intact cognition according to mental status testing, making the medication's disappearance particularly concerning given the resident's awareness of their treatment needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Marshalltown from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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