Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 50. The facility's policy required nurses to document all medications administered on the resident's medication administration record (MAR). However, for Resident 50, there was no documented evidence that doses of Oxycodone HCL, a narcotic drug prescribed for moderate to severe pain, were administered on two specific occasions in December 2024, despite being signed out for administration. Resident 50 had mild cognitive impairment and was able to understand and communicate with others. The resident was experiencing pain and had physician's orders for Oxycodone HCL to be administered as needed. The Director of Nursing confirmed the lack of documentation for the administration of the medication on the specified dates, indicating a failure to adhere to the facility's medication administration policy.
Plan Of Correction
1. The medication administration record for R50 cannot be corrected. 2. The Director of Nursing or designee will audit current resident's controlled substance accountability records for accuracy of administration times in comparison to the medication administration record (MAR). 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the facility policy and procedure for administration of controlled substances. 4. The Director of Nursing or designee will audit 25% per unit of all administered controlled substances for accurate documentation at the time of administration. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.