Inaccurate Controlled Medication Records and Administration
Penalty
Summary
The facility failed to implement proper procedures for maintaining accurate controlled medication records and ensuring medication availability for a resident. Specifically, the controlled substance record for Morphine Sulfate Solution prescribed to a resident for severe pain showed that doses were signed out on multiple occasions, but there was no corresponding documentation on the Medication Administration Record (MAR) to confirm that the medication was administered. This discrepancy was confirmed by the Director of Nursing during an interview, highlighting inconsistencies in the controlled medication records. The resident involved was admitted with diagnoses including dementia and polyneuropathy and had a history of severe pain requiring both daily and as-needed pain medications. Despite the physician's order for Morphine Sulfate Solution to be administered as needed for severe pain, the lack of documentation on the MAR raised concerns about whether the resident received the necessary medication. The resident's cognitive impairment further complicated the situation, as they were unable to provide information regarding their pain or medication regimen during an interview.
Plan Of Correction
Resident 28 was discharged from the facility. The facility cannot retroactively correct missing documentation on the MAR. Licensed nursing staff will be educated on the Medication Administration policy. Medication Administration Competencies will be completed for Licensed nursing staff. Random weekly audits will be conducted by the DON/designee on controlled medication to ensure that the Narcotic sign out matches the MAR x4 weeks then monthly x 2. Results of the audits will be reviewed at monthly QAPI x 3 months.