Failure to Document Administration of Controlled Medications
Penalty
Summary
Mulberry Healthcare and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding pharmacy services. The facility failed to ensure the accountability of controlled medications for two residents. For Resident 2, who was cognitively intact and required assistance for daily care needs, there was a physician's order for 325 mg of Oxycodone-Acetaminophen to be administered every 12 hours as needed. However, a review of the controlled drug record for January 2025 showed that a dose was signed out on January 8, 2025, but there was no documented evidence in the resident's clinical record that the medication was administered. Similarly, for Resident 5, who was cognitively impaired and required assistance with daily care needs, there was a physician's order for 5 mg of Oxycodone to be administered every eight hours as needed. The controlled drug record for January 2025 indicated that a dose was signed out on January 14, 2025, but again, there was no documented evidence in the clinical record that the medication was administered. An interview with the Director of Nursing confirmed the lack of documentation for the administration of Oxycodone to both residents on the specified dates.
Plan Of Correction
Residents R2 and R5 were not adversely affected and were provided pain medications as needed as evidenced on the Controlled Narcotic Sign Out Sheet. The Licensed Practical Nurse who missed a signature on the Medication Administration Record was provided re-education/disciplinary action regarding the missed signature. The Director of Nursing is completing an audit of all current Controlled Narcotic Sign Out Sheets for the past two weeks to ensure that a corresponding notation is present in the Resident's Electronic Medication Administration Record. All licensed nurses will be re-educated regarding ensuring signatures are present on both documents for any controlled substances provided. An additional check will be initiated with each change of shift for two nurses to verify all controlled substances given during the shift have a corresponding notation in the Electronic Medical Record. The Director of Nursing or designee will complete random double checks of the documents to ensure both signatures are present daily x5, then weekly x4, then monthly x2 with results to Quality Assurance.