Failure in Controlled Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate accounting and administration of controlled medications for a resident, leading to a deficiency in pharmacy services. A review of the clinical records and controlled drug records revealed that a resident, admitted with cervical spondylosis, history of falls, and transient ischemic attacks, had a physician's order for Percocet 5-325 mg, ½ tablet by mouth once daily at bedtime. However, on December 25, 2024, a registered nurse signed out a dose of Percocet for the resident at 4:00 AM but failed to document the administration in the medication administration record (MAR) as required. Further investigation showed that the nurse administered the medication outside the prescribed bedtime schedule, mistakenly believing it was a PRN order, despite the PRN order being discontinued earlier in the month. This error was documented in a safety event report, and it was confirmed that the nurse did not recognize the discontinuation of the PRN order, leading to the medication error. The facility's failure to adhere to procedures and protocols for the accurate administration and documentation of controlled substances compromised the integrity of the controlled medication records.
Plan Of Correction
Step 1 Resident #1 had a head-to-toe assessment completed upon discovery of medication error, no adverse effects were identified, and MD/RP notification was completed. Step 2 To identify other Residents with the likelihood to be affected, the DON/Designee will audit Declining Count Narcotic logs of all controlled substances for the past 14 days to ensure all medications were administered and documented in the Emar logs as per physician orders. Any medication found to be administered in error will have a Medication Error event report completed with proper MD/RP notification. Step 3 To prevent a future recurrence, the DON/Designee will educate all licensed nurses on the 5 Rights of medication administration, including the proper procedure to follow if a change in direction sticker is present on a medication card or narcotic log. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will complete a Medication Pass competency on 5 Random licensed nurses weekly x 4 and then monthly x 2. To monitor and maintain ongoing compliance, the NHA/Designee will interview 3 Random licensed nurses on proper procedure to follow during medication pass, if a change in direction sticker is present on a medication card or narcotic log, weekly x 4 and then monthly x 2. To monitor and maintain ongoing compliance, the DON/Designee will audit all Declining Count Narcotic logs to ensure the medication was documented in the Emar and on the log as per physician orders, 3x/week x 4 weeks, and then weekly x 8 weeks. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.