Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate and clear documentation of controlled substance counts and administration, impacting nine residents across two medication carts. Registered Nurse (RN) JJ did not administer a resident's prescribed Tramadol as scheduled because it was not available in the medication cart, and subsequently administered the medication later without proper documentation or a physician's order for the late dose. RN JJ also failed to document the administration of controlled substances on the appropriate inventory sheets, instead recording them on a separate piece of paper with the intention to update the records later. This led to discrepancies between the actual medication counts and the documented inventory for multiple residents. Observations and interviews revealed that controlled substance counts for several residents did not match the inventory sheets, with pills unaccounted for in multiple cases. For example, one resident's Tramadol card had fewer pills than indicated on the inventory sheet, and similar discrepancies were found for other controlled medications such as Clonazepam, Oxycodone, Morphine, Hydrocodone/Acetaminophen, and Hydromorphone. Additionally, an LPN reported signing out a medication that was later refused by a resident, but the MAR indicated the medication was administered and effective, showing conflicting documentation. Another instance involved a nurse possibly administering medication to the wrong resident with a similar order. Further review determined that RN JJ had taken Tramadol from one resident's supply and administered it to another without proper documentation, and attempted to return medication to the original card from the backup supply. The Director of Nursing confirmed multiple errors in documentation and administration, including actual medication errors and failure to follow professional standards and facility policy. The facility's records and staff interviews consistently showed a lack of adherence to required procedures for controlled substance management and documentation.