Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically for one resident who was prescribed acetaminophen-codeine for pain management. On the observed date, a medication aide (MA) prepared and administered the resident's scheduled dose of acetaminophen-codeine but did not document the administration on the resident's narcotic record as required. The MA acknowledged forgetting to sign the narcotic record due to being nervous while observed by a surveyor and recognized that this omission could result in a miscount of controlled medications. The resident involved was an older adult with chronic obstructive pulmonary disease, diabetes, and heart failure, who was cognitively intact and received regular opioid medication for pain. Interviews with the Director of Nursing (DON) and the Administrator confirmed that facility policy requires immediate documentation of controlled substance administration on the narcotic record by the person administering the medication. Both stated that failure to document could cause discrepancies in the controlled drug count. Review of facility policies further indicated that controlled substances must be reconciled upon administration and that the administering nurse is responsible for recording all required details immediately after giving the medication.