Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 26. The facility's policy required that the individual administering medication must initial the resident's Medication Administration Record (MAR) after giving each medication. However, there was no documented evidence in Resident 26's clinical record, including the MAR, that the signed-out doses of Tramadol, a narcotic pain medication, were administered on specific dates and times in January and February 2025. Resident 26 was cognitively intact and required assistance with personal care needs, with diagnoses including stroke and diabetes. Physician's orders indicated that the resident was to receive 25 mg of Tramadol every eight hours as needed for pain. Despite the controlled drug record showing that Tramadol was signed out on several occasions, the Director of Nursing confirmed that there was no documentation in the resident's clinical record to indicate that these doses were administered.
Plan Of Correction
Resident 26 MAR was reviewed and reconciled. Residents with orders for controlled medication have the potential to be affected. Director of Nursing provided education to licensed nurses on documentation of controlled medication administration and controlled medication reconciliation. Monitoring will be captured through auditing Medication administration. Audits will be completed as follows: 2 staff med pass observations will be conducted weekly for 4 weeks, then 4 staff med pass observations will be conducted 2 times monthly for 2 months. Results of the med pass observations will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.