Controlled Medication Discrepancy for Resident
Penalty
Summary
The facility failed to ensure an accurate account of controlled medications for a resident diagnosed with dementia and major depressive disorder. The resident was prescribed ABHR Cream, a controlled drug, to be applied topically every 12 hours as needed. A review of the Control Substance Record revealed discrepancies in the medication count. Initially, 30 grams of ABH gel were received, and the first dose was signed out on 1/23/25, with a remaining count of 28 mL instead of the expected 29 mL. Subsequent records showed further discrepancies, with the count on 2/1/25 being 24 mL when it should have been 27 mL. There was no documentation explaining these discrepancies. Interviews conducted during the investigation revealed that the Director of Nursing (DON) could not account for the discrepancies and suggested that air in the medication container might have contributed to the issue. However, a pharmacy technician confirmed that the facility received 30 mL of ABH cream and that each click of the dispenser equaled 0.25 mL, requiring four clicks for a 1 mL dose. The pharmacy technician also stated that air in the bottle would not cause a discrepancy in the medication count. The facility did not have any ABHR gel/cream available at the time of the investigation.
Plan Of Correction
Element 1: Resident 17 controlled substance sheets were reviewed by the Director of Nursing. There are no inaccurate counts on current controlled medications. Element 2: A one-time audit was completed by the clinical team of active controlled substance orders to ensure accurate counts. No inaccurate counts were found during this audit. Element 3: The Director of Nursing was re-educated on medication administration and accurate counts for controlled substances by the Regional Director of Clinical Services. Licensed nurses have been re-educated on ensuring accurate counts when administering and documenting controlled substances. At shift change, nurses will review counts, and if any inaccuracy is noted, the DON or designee will be notified. A daily review, Monday through Friday, will be completed by nurse managers to ensure controlled substance use sheets are accurate. The QAPI Committee reviewed the policy, "Medication Administration," and deemed it appropriate. Element 4: An audit will be completed weekly for four weeks, then monthly, of nine residents with controlled substance orders to ensure accurate counts. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and sustaining compliance.