Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents during a random audit. For one resident, Hydrocodone-Acetaminophen was documented as administered on the Medication Administration Record (MAR), but the dose was not signed out on the Controlled Drug Record (CDR). The responsible RN confirmed during interview that the medication was given but the CDR was not signed at the time of administration. For two other residents, controlled medications (Norco and Oxycodone Hydrochloride) were signed out of the CDR, indicating removal from the medication cart, but the administration was not documented on the MAR. The Director of Nursing (DON) acknowledged during interviews that the medications were not properly accounted for in the MAR. A review of the facility's policies confirmed that staff are required to document the administration of controlled substances both in the narcotic book (CDR) and on the MAR, in accordance with applicable law and facility procedures. The failure to consistently document controlled medication administration in both records resulted in inaccurate accountability of these medications.