Bridgeville Rehab: Missing Oxycodone Investigation - PA

Federal inspectors found that Bridgeville Rehabilitation & Care Center failed to protect residents from theft of their property during a November incident involving missing controlled substances. The facility ultimately filed a police report but told inspectors they were unable to identify who took the drugs.

Only two registered nurses had keys to access the medication cart during the timeframe when the oxycodone disappeared. RN Employee E4 and RN Employee E5 were the sole staff members with access from 11:00 p.m. on November 7 through 10:15 a.m. on November 9, when Employee E5 left her shift due to a family emergency.

The problems began surfacing during the overnight shift on November 9. When Resident R1 requested her prescribed Oxycodone HCL 5 mg at approximately 4:45 a.m., RN Employee E4 couldn't find the medication in the narcotic drawer. Both the narcotic card and narcotic tracking sheet were missing.

RN Employee E4 had counted 27 narcotic cards in the drawer just hours earlier at 11:06 p.m. and signed that the count was correct. But when the resident needed her pain medication before dawn, the oxycodone was nowhere to be found.

The nurse's written statement described the confusion: "I looked for the controlled substance tracking sheet and card, there were none. I flipped to the shift change inventory count signoff sheet from the prior day and it was missing."

Licensed Practical Nurse Employee E6 became involved when RN Employee E4 asked for help. The resident told staff she had been receiving pain medication regularly, but there was no computer documentation showing the pills had been dispensed.

During their search, LPN Employee E6 made a disturbing discovery. She found the missing narcotic count signoff sheet folded in half in the recycle bin. The document contained RN Employee E4's acknowledgement of receiving the oxycodone card and the card identification number, but it was unsigned by RN Employee E5 during the shift change.

Facility policy requires that the nurse coming on shift must verify the count of all controlled substances with the nurse going off shift whenever medication cart keys are exchanged. The unsigned sheet suggested this critical safety protocol had been skipped.

The investigation revealed additional irregularities. RN Employee E5 had documented counting "27 of 27 narcotic cards" at 11:00 p.m., but RN Employee E4's earlier documentation from November 8 showed "29/29 narcotic cards." Somehow, two narcotic cards had gone missing between shifts, but there was no explanation for the discrepancy.

RN Employee E5's written statement offered little clarity. She claimed she "never gave Resident R1 a pain pill other than Tylenol as she did not request for anything stronger." She also noted that around 1:00 p.m. on November 8, "the binder fell off the med cart and RN Employee E5 had to put all the papers back in the narcotic book."

The missing documentation created a dangerous gap in the medication tracking system. LPN Employee E6 and RN Employee E4 discovered that someone had removed the original tracking sheet and placed a new one in the controlled substance tracking book. The replacement document lacked RN Employee E4's November 8 documentation acknowledging receipt of the oxycodone card.

Despite their extensive search, staff never found the missing oxycodone pills or the corresponding drug count record that should have been in the binder.

The resident's pain went untreated for over an hour. She didn't receive her prescribed oxycodone until 6:00 a.m. on November 9, more than 75 minutes after her initial request.

The facility's response raised additional questions. There was no evidence that administrators interviewed RN Employee E5 about why she failed to sign the shift change count sheet on November 8 at 7:00 a.m., or how the narcotic card count mysteriously changed from 29 to 27 between her shifts. Inspectors also found no evidence that anyone interviewed the resident about the missing medication.

The Director of Nursing confirmed during a December 22 interview that only the two registered nurses had access to the medication cart during the critical timeframe. The facility determined they couldn't identify who took the drugs and filed a report with local police.

In response to the incident, facility administrators conducted education sessions in November covering policies on abuse, neglect and exploitation. They confirmed the training through staff interviews.

During their December 26 inspection, federal investigators interviewed the Nursing Home Administrator and Director of Nursing. Both confirmed that the facility had failed to ensure residents are free from misappropriation of property.

The violation affected one of four residents reviewed during the inspection. Inspectors cited the facility under federal regulations requiring nursing services and protecting resident rights.

The missing medication case illustrates broader vulnerabilities in controlled substance security at nursing homes. When tracking systems fail and accountability measures break down, residents like R1 suffer the immediate consequences - waiting in pain while staff scramble to locate missing drugs and reconstruct paper trails that should never have been compromised.

The resident's hour-long wait for pain relief represents more than an administrative failure. It demonstrates what happens when the systems designed to protect vulnerable residents and their prescribed medications collapse, leaving both patients and honest staff members to navigate the aftermath of someone else's actions.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Bridgeville Rehabilitation & Care Center from 2025-12-26 including all violations, facility responses, and corrective action plans.

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