LPN #480 was terminated December 25th after a facility investigation revealed multiple medication discrepancies involving controlled substances. The nurse had removed Percocet from the controlled drug record on three separate occasions in early December but failed to document administering the medication to Resident #12.
On December 7th at midnight, 5:42 a.m., and again at 12:00 a.m., the nurse signed out Percocet for "as needed" administration according to the controlled drug record. None of these removals appeared on the medication administration record, which nurses are required to complete for all medications given to residents.
Resident #12 complained directly to LPN #416 that LPN #480 had not administered her prescribed Percocet but gave her Tylenol instead. LPN #416 immediately notified corporate officials, and LPN #480 was sent home while the facility launched an investigation.
The complaint was not isolated. During interviews December 22nd, the administrator revealed that Resident #12 had complained about LPN #480 taking her medications several months before this December incident came to light.
Director of Nursing confirmed that nurses must document controlled medications on both the medication administration record and the controlled drug record to prevent errors. The dual documentation requirement exists specifically because controlled substances carry higher risks for diversion and abuse.
When LPN #480 was drug tested as part of the investigation, results showed benzodiazepines in her system without an active prescription. The facility terminated her employment December 25th for violating the drug policy.
The facility filed a police report with local authorities. Officials also notified the Ohio Department of Health, Ohio Board of Nursing, and Ohio Board of Pharmacy about the investigation findings.
The administrator stated during interviews that LPN #480 had no other substantial violations related to medication documentation errors beyond this incident. However, the earlier complaints from Resident #12 suggest a pattern the facility had not previously investigated.
Facility policy on administering medications, revised in April 2019, requires all medication errors to be documented, reported, and reviewed by the quality assurance committee. The policy states that when drugs are withheld, refused, or given at times other than scheduled, nurses must initial and circle the entry on the medication administration record.
The policy also mandates that all medications administered be documented on the medication administration record. LPN #480's failure to document the three Percocet administrations while signing them out of the controlled drug record violated this requirement.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. The investigation was conducted under Master Incident Number 2692300 following a complaint to state authorities.
The case highlights ongoing challenges nursing homes face with controlled substance management. When nurses have access to pain medications like Percocet, facilities must maintain strict tracking systems to prevent diversion while ensuring residents receive prescribed pain relief.
For Resident #12, the substitution of Tylenol for prescribed Percocet meant she received inadequate pain management. Percocet contains both acetaminophen and oxycodone, providing stronger pain relief than Tylenol alone for residents with conditions requiring controlled pain medication.
The facility's quality assurance committee will review the incident to determine if additional staff training or process changes are needed to prevent similar medication errors. The termination and regulatory notifications demonstrate the serious consequences nurses face when diverting controlled substances from residents who depend on them for pain management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Assumption Village from 2025-12-23 including all violations, facility responses, and corrective action plans.
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