Failure to Accurately Document and Administer Controlled Medication
Penalty
Summary
Staff failed to maintain a complete and accurate medical record for a resident prescribed pregabalin, a controlled substance, for neuropathy and pain. On multiple occasions, the Medication Administration Record (MAR) indicated that the medication was administered, with signatures from various nurses and a medication aide. However, corresponding entries were missing from the controlled medication declining sheets, and staff interviews confirmed that the medication was not actually given on those dates, despite being signed as administered on the MAR. The controlled medication count was also correct, further indicating that the doses were not dispensed. Interviews with the involved staff, including nurses and a medication aide, revealed that they did not administer the medication even though they had signed for it on the MAR. The Director of Nursing and Medical Director both stated that accurate and honest documentation is expected on both the MAR and the narcotic record. The administrator also confirmed the expectation that medications are administered as ordered and documented accurately. The failure to document and administer the medication as ordered resulted in incomplete and inaccurate medical records for the resident.