Failure to Accurately Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to accurately inventory and reconcile a resident's controlled medication, morphine sulfate, with the Medication Administration Record (MAR). The resident, who was admitted with diagnoses including type 2 diabetes mellitus, dementia, and was receiving palliative care, was severely cognitively impaired and dependent on staff for daily activities. The resident had a physician's order for scheduled morphine sulfate for pain management. Record reviews and interviews revealed that while the resident's MAR indicated morphine sulfate was administered daily at 6:00 p.m. on several dates, the Individual Narcotic Record (INR) was missing corresponding entries for those administrations. The Assistant Director of Nursing confirmed these omissions. Facility policy required that controlled substance inventory be regularly reconciled to the MAR, but this was not done, resulting in incomplete documentation of the use and removal of the resident's morphine sulfate.