Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for several residents. In multiple instances, nursing staff signed out controlled medications from the Controlled Drug Record (CDR) but did not document the administration of these medications on the Medication Administration Record (MAR). This discrepancy was identified for four out of five residents reviewed, with specific examples including missed documentation for oxycodone and hydrocodone/acetaminophen administrations. The Assistant Director of Nursing (ADON) confirmed that these administrations should have been recorded on the MAR, as required by facility policy. Additionally, the facility did not consistently follow its policy for the proper disposal (wasting) of controlled medications. The records showed that wasted medications for several residents were not co-signed by a second nurse, as mandated by the facility's procedures. Specific instances included wasted doses of oxycodone, diazepam, and buprenorphine without the required witness signature. Both the Director of Nursing (DON) and a Registered Nurse (RN) acknowledged that the double signature was missing in these cases and confirmed that the policy requires two signatures for wasted controlled substances. A review of the facility's policies confirmed that staff are required to document medication administration on the MAR and to have two signatures for the wasting of controlled substances. The survey findings demonstrated that these procedures were not consistently followed, resulting in incomplete records for both the administration and disposal of controlled medications.