Deficiencies in Controlled Substance Accountability and Medication Availability
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substances for a resident with a physician's order for tramadol. There were discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR), with instances where medication was removed from the cart but not documented on the MAR, and vice versa. Both the licensed nurse and the Director of Nursing confirmed that facility policy required documentation on both records immediately after administration, and that these discrepancies were present for the resident in question. Additionally, the facility did not consistently obtain signatures from both off-going and on-coming nurses on the controlled drug shift-to-shift count records for multiple medication carts. Several shifts were missing required signatures, which are necessary to confirm that controlled medication counts were completed and that no discrepancies were identified during shift changes. Both nursing staff and the Director of Nursing acknowledged that this was not in accordance with facility policy, which mandates special handling and record keeping for controlled substances. The facility also failed to replace a narcotic emergency kit (e-kit) in a timely manner after it was opened, as required by policy. The opened kit was found with a red plastic tie and logs indicating medication had been removed, but the kit had not been reordered from the pharmacy. Furthermore, a resident with diabetes did not receive a scheduled dose of Ozempic because the medication was pending delivery from the pharmacy, and there was no documentation that the family had been contacted to supply the medication, despite the expectation that such communication should occur and be documented.