Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. The facility's policy required staff to document the administration details of controlled substances, including the time, day, amount administered, and remaining quantity. However, for one resident, there was no documented evidence in the clinical records, including the Medication Administration Record (MAR), that doses of Ativan, a controlled medication, were administered on specific dates and times, despite being signed out. The resident involved had a diagnosis that included depression and required assistance with all care needs. Physician's orders indicated the resident was to receive Ativan as needed for restlessness and anxiety. Despite the orders, the controlled drug records showed discrepancies, with doses signed out but not documented as administered. The Director of Nursing confirmed the lack of documentation for the administration of these doses.
Plan Of Correction
Immediate education was provided to the licensed staff who failed to indicate on the medication administration record that an as needed medication was given. A whole house audit will be conducted to confirm narcotics that have been signed out are initialed on the medication administration record. All licensed staff will be re-educated on the facility's controlled substance policy. The Director of Nursing or designee will audit 5 narcotic sheets a week for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.