Failure to Accurately Manage and Document Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the accurate acquisition, receipt, dispensing, administration, and recordkeeping of medications, particularly controlled substances, for several residents. In one instance, a resident with severe cognitive impairment had a discontinued order for Clonazepam that remained in the medication cart, and the medication label did not match the order in the resident's medical record. Both the RN and the DON acknowledged that the medication should have been removed when discontinued, and that the documentation on the medication bingo card and control record did not align with the physician's order. For another resident with multiple psychiatric diagnoses, a review of the controlled substance record for Clonazepam revealed discrepancies in the documentation of the number of tablets on hand and those administered, with no explanation for the inconsistencies. Similarly, a resident with diabetes and other complex conditions had discrepancies in the administration and documentation of Tramadol, including tablets being removed from the controlled substance box without corresponding documentation on the Medication Administration Record (MAR), and instances where more tablets were removed than documented as administered. The staff involved were unable to explain these discrepancies during interviews. Additionally, a resident with a recent femur fracture and good cognitive status had a controlled drug signed out as administered, but there was no documentation in the MAR to confirm administration. Staff interviews confirmed that the expected process is to document administration both on the controlled drug record and the MAR, but this was not done. The DON acknowledged that reconciliation of controlled substances is supposed to occur at every shift change, but the observed discrepancies indicate this was not consistently followed.