Failure to Accurately Document Administration of Controlled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, there were inconsistencies between the documentation of narcotic medications signed out on the narcotic count sheets and the documentation of those medications administered as reflected on the Medication Administration Records (MAR) and nursing progress notes. This deficiency was identified for five residents who were reviewed for pharmacy services, all of whom had orders for controlled pain medications such as Tramadol, Tylenol with Codeine, and hydrocodone/APAP. In multiple instances, medications were signed out on the control drug records but not documented as administered on the MAR or in the nursing notes, and vice versa. The residents involved had varying degrees of cognitive impairment and complex medical histories, including conditions such as hypertension, stroke, dementia, chronic pain, and other comorbidities. For example, one resident with severe cognitive impairment and multiple diagnoses had Tramadol signed out on the control drug record on several dates, but the MAR and nursing notes did not reflect administration of those doses. Similar discrepancies were found for other residents, with controlled medications being signed out but not documented as given, or lacking corresponding nursing notes to support administration. Interviews with residents indicated that they generally felt their pain was managed, but the documentation did not support that medications were administered as ordered. Staff interviews revealed that nurses were required to count controlled medications at shift changes and document administration on both the MAR and narcotic count sheets. However, some staff admitted to missing MAR entries, often due to distractions, and recognized the importance of proper documentation for communication and assessment purposes. The Director of Nursing and other staff identified that two nurses were primarily responsible for the documentation failures, and an internal audit confirmed multiple instances of incomplete or missing documentation for PRN controlled medications. The facility's policies required accurate and timely documentation of medication administration, but these procedures were not consistently followed, resulting in the identified deficiency.