Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that the Antibiotic or Controlled Drug Record accurately matched the quantity of controlled medications present in the medication bubble packs for three residents. During an observation and record review, discrepancies were found between the documented counts on the accountability logs and the actual number of medication doses remaining in the bubble packs for hydrocodone-acetaminophen, pregabalin, and lorazepam. Specifically, one dose each of hydrocodone-acetaminophen and lorazepam was missing for two residents, and both a pregabalin capsule and a hydrocodone-acetaminophen tablet were missing for another resident, with no documentation of administration for these doses. The residents involved had medical histories including chronic pain, osteoarthritis, neuropathy, and anxiety, and were prescribed controlled medications for these conditions. The discrepancies were identified during a medication cart audit, where it was found that the number of doses in the bubble packs did not align with the amounts recorded on the accountability logs after the last documented administration. There was no evidence in the records to account for the missing doses, and the medication administration records did not reflect any additional administrations. A Licensed Vocational Nurse admitted to administering the missing doses to the residents earlier that day but failed to sign off on the Antibiotic or Controlled Drug Record accountability logs as required by facility policy. The Director of Nursing confirmed that the nurse did not follow the policy of immediate documentation on the accountability records when preparing and administering controlled medications. The facility's policy requires that the administering nurse immediately document the date, time, amount, and signature on the accountability record at the time the medication is removed from the supply.