Failure to Document Controlled Substance Administration per Policy
Penalty
Summary
A staff member failed to follow facility policy regarding the documentation of controlled substances during medication administration. Specifically, Nurse #1 administered a controlled medication, Oxycodone 10mg, to a resident for pain management but did not immediately document the administration on the controlled medication count sheet as required by facility policy. The policy mandates that the licensed nurse must immediately record the date and time of administration, amount administered, remaining quantity, and their initials on the accountability record and medication administration record after giving the medication. This deficiency was identified during an observation of a medication pass, where Nurse #1 was seen administering the medication but not signing it out on the count sheet. In subsequent interviews, Nurse #1 acknowledged the omission and confirmed awareness of the correct procedure. The DON also confirmed that the expected process was not followed in this instance.