Failure to Accurately Reconcile and Document Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled medications for two residents, resulting in incomplete records and unaccounted controlled substances. For one resident with diagnoses including cerebral palsy, spondylosis, contractures, and cervical disc disorder with myelopathy, a medication monitoring record for oxycodone 15 mg was found misplaced in a binder. The record, covering several days, showed multiple documentation errors such as missing dates, times, signatures, and amounts administered or remaining. Additionally, the final count did not account for two remaining oxycodone tablets, and the process for staff reconciliation did not consistently involve both staff members observing the controlled medication during shift changes. Another incident involved a resident with anxiety, COPD, and chronic respiratory failure, who alleged that a nurse had not been administering her prescribed oxycodone 15 mg but was instead giving her allergy pills. A nurse discovered a white pill, not matching the prescribed oxycodone, taped into the resident's oxycodone packet. The nurse also noted that the oxycodone packet was not present during the morning controlled substance reconciliation, raising further concerns about the accuracy and integrity of the medication administration and documentation process. The facility's policy required maintaining a signed medication count record for controlled substances, but the observed practices and documentation did not meet this standard. The deficiencies included incomplete and inaccurate medication monitoring records, lack of proper reconciliation procedures, and failure to account for all controlled drugs, as evidenced by the findings for both residents.