Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that controlled substance medications were fully accounted for on the Medication Administration Record (MAR) for three out of six residents reviewed. In multiple instances, nursing staff signed out controlled medications from the Controlled Drug Record (CDR) but did not document the administration of these medications on the MAR. Specifically, for one resident prescribed Butalbital-Acetaminophen-Caffeine for severe migraines, three tablets were signed out in the CDR but not recorded as administered on the MAR on three separate occasions. Another resident with an order for Hydrocodone-Acetaminophen for pain management had one tablet signed out in the CDR without corresponding documentation on the MAR. A third resident receiving Tramadol for pain had two tablets signed out in the CDR that were not documented on the MAR. These discrepancies were verified by the Regional Nurse Consultant (RNC) during concurrent interviews and record reviews, who acknowledged that the medications were not properly accounted for in both the CDR and MAR. The Pharmacy Consultant also confirmed that documentation should occur in both records to prevent medication diversion. The facility's policy requires that the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the MAR and CDR, but this protocol was not followed in the cited cases.