Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain a comprehensive system of records for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation. This deficiency was identified during a review of records for a resident who was prescribed controlled medications. The facility's policy on controlled substances requires that each dose administered be documented on both the control sheet and the electronic medication administration record (eMAR). However, discrepancies were found in the documentation for a resident who had been prescribed a 50 mg oral tablet to be taken as needed. Specifically, the controlled medication utilization record indicated that tablets were removed at specific times, but there was no corresponding documentation in the medication administration record for those times. Interviews with facility staff, including a registered nurse and a licensed practical nurse, revealed that the process for handling controlled medications involves removing the medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this procedure, the records for the resident in question were incomplete, indicating a failure to adhere to the established protocol. This lapse in documentation and record-keeping for controlled substances was observed for one of the five sampled residents, highlighting a significant oversight in the facility's pharmacy services.
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 centers 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, residents, level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring 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.