Failure to Document Controlled Substance Administration in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents, specifically regarding the documentation of controlled substance administration. According to the facility's medication administration policy, staff are required to document the administration of controlled substances in accordance with applicable law, including recording each dose on the appropriate controlled medication record. However, for all five residents reviewed, there were multiple instances where narcotic pain medications such as Tramadol, oxycodone-acetaminophen, oxycodone, and hydrocodone-acetaminophen were administered as documented on the Medication Administration Record (MAR), but there was no corresponding documentation on the controlled medication record for those administrations. The residents involved were all cognitively intact and required assistance with care needs. Each had significant pain management needs and diagnoses such as multiple sclerosis, chronic pain, polyneuropathy, spinal stenosis, osteoarthritis, fibromyalgia, and fractures. Physician orders for these residents included scheduled and as-needed administration of opioid medications for pain control. Despite these orders and the administration of the medications as recorded on the MAR, the required documentation on the controlled medication record was missing for several dates and times for each resident. The Director of Nursing confirmed during an interview that there was no documented evidence on the controlled medication sheets for the administration of the specified medications to the five residents on the identified dates and times. This lack of documentation was found to be inconsistent with both facility policy and regulatory requirements for clinical records and nursing services.