Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
Facility staff failed to accurately document the administration of temazepam 15 mg for one resident. Specifically, a Licensed Vocational Nurse (LVN) administered temazepam to the resident after the resident complained of an inability to sleep, but the LVN recorded the date of administration incorrectly on the Controlled Drug Record (CDR), entering the previous day's date instead of the actual date the medication was given. This error was identified during a review of records and confirmed in an interview with the LVN, who acknowledged the importance of accurate documentation to prevent confusion for subsequent staff. The resident involved had been admitted with chronic kidney disease stage 3, essential hypertension, and muscle weakness. The Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact and that they required partial to moderate assistance with certain activities of daily living. The medication order for temazepam specified administration as needed for insomnia, with a start date documented in the resident's Order Summary Report. Facility policy and procedure for controlled medications required that the licensed nurse immediately document the date and time of administration, the amount administered, and provide their signature on the accountability record at the time the medication is removed from supply. The nurse was also required to initial the Medication Administration Record (MAR) after administration. The failure to document the correct date on the CDR was contrary to these established procedures.