Failure to Accurately Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the Controlled Drug Record for two residents who were receiving controlled medications for pain management. In the first instance, a resident with diagnoses including radiculopathy, cervicalgia, and low back pain was prescribed pregabalin 25mg three times daily. After administration of the morning dose, the nurse did not document the removal of the medication on the Controlled Drug Record, resulting in a discrepancy between the number of doses recorded and the actual number left in the bubble pack. The nurse acknowledged the omission and confirmed that facility procedure required documentation of each dose removed. In the second instance, another resident with a history of surgical amputation and a stage three pressure ulcer was prescribed tapentadol 100mg twice daily. The nurse administered the medication but failed to document it on the Controlled Drug Record, leading to an inaccurate count of remaining doses. Both nurses involved stated they were responsible for documenting each administration on the Controlled Drug Record as per facility policy, which was not followed in these cases. The facility's policy required licensed nurses to record administered controlled medications on both the MAR and the narcotic count sheet.