Failure to Accurately Document and Provide Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability and administration of controlled drugs for three residents. For one resident with anxiety, there were three occasions where nursing staff signed out diazepam on the Controlled Drug Record (CDR) but did not document administration on the Medication Administration Record (MAR), as confirmed by the Director of Nursing (DON). For another resident with type 2 diabetes mellitus, a nurse signed out oxycodone-acetaminophen on the CDR but failed to document administration on the MAR. Facility policy requires that the date, time, dosage, and signature of the person administering the medication be recorded in the resident's medical record and on the CDR for controlled substances. Additionally, a resident with Parkinson's disease did not receive a scheduled dose of carbidopa-levodopa because the medication was not available at the time of administration. The nurse indicated the medication was ordered from the pharmacy, but the dose was missed. Facility policy states that medications should be administered within one hour of their prescribed time and that medications should be available at all times. The DON confirmed that nurses are expected to order medications in advance to prevent running out.