Failure in Controlled Drug Record-Keeping
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically for one resident. The facility's policy on controlled substances management requires strict handling, storage, disposal, and record-keeping, including signing off each dose on the control sheet and electronic medication administration record (eMAR). However, a review of the records for a resident revealed discrepancies in the documentation of controlled medication administration. Specifically, there was no documentation on the eMAR for doses of a controlled medication that were removed from the supply at 1:30 AM and 7:00 AM on a particular day. Interviews with nursing staff revealed inconsistencies in the process of documenting the administration of controlled medications. A registered nurse and a licensed practical nurse both described the procedure of removing medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this, the records for the resident in question did not reflect the administration of the medication as per the facility's policy, indicating a failure in the system of record-keeping for controlled substances.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #4, screening completed, resident's level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medication administrations are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. Identification of other residents potentially affected: Quality review audit of completed. Current residents have the potential to be affected; resident #4 was not affected. Measures: On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medications administration are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. In-services/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure records are in order and that an account of all controlled drugs is maintained and reconciled. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.