Failure to Document and Administer Controlled Medications per Provider Orders
Penalty
Summary
The facility failed to accurately document the administration of controlled medications and did not ensure that controlled medications were administered according to provider orders for four residents. For one resident, temazepam was not documented as dispensed on the Controlled Substances Proof of Use form, despite being recorded as administered on the Medication Administration Record. Additionally, lorazepam was dispensed and documented prior to the start date of the order and after the order had expired, with no corresponding documentation of administration or a physician's one-time order in the medical record. Another resident had lorazepam dispensed on multiple occasions without an active order, and there was no documentation of administration or a physician's order for those instances. For two other residents, hydrocodone-acetaminophen and lorazepam were dispensed as indicated on the Controlled Substances Proof of Use forms, but there was no documentation on the Medication Administration Record that these medications were administered. The lack of documentation for as-needed medication administration impedes the ability to assess ongoing need and symptom control. The DON and NHA confirmed these medication administration and documentation errors during interviews, and facility policy requires medications to be administered per physician orders and documented accordingly.