Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for three out of five residents reviewed. Facility policy required documentation of controlled substance administration in accordance with applicable law, including recording when medications are given on appropriate forms. For three residents, controlled drug records showed that doses of narcotic pain medications were signed out on specific dates and times. However, there was no corresponding documentation in the residents' clinical records or Medication Administration Records (MAR) to confirm that these medications were actually administered at those times. The residents involved were cognitively intact and had significant pain management needs, with diagnoses such as fractures, osteoarthritis, chronic pain syndrome, fibromyalgia, and polyneuropathy. Each had physician orders for opioid or narcotic pain medications, either scheduled or as needed. Despite these orders and the signing out of medications on controlled drug records, the lack of documentation in the MAR or clinical records was confirmed by the Director of Nursing, indicating a failure to ensure proper tracking and accountability for controlled substances as required by facility policy and state regulations.