Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its policies and procedures for two residents. For one resident with the capacity to make decisions, a physician's order was in place for oxycodone-acetaminophen to be administered as needed for moderate to severe pain. The medication was dispensed and signed out, but there was no documentation of its administration on the Medication Administration Record (MAR) for the specified date and time. This omission was verified during a medical record review and interview with a registered nurse. Similarly, for another resident who was unable to make decisions, a physician's order was in place for lorazepam to be administered as needed for anxiety. The medication was dispensed and signed out, but again, there was no documentation of its administration on the MAR for the specified date and time. This finding was also confirmed through medical record review and staff interviews. The facility's policies require that the administration of controlled substances be documented on the MAR, including the date, time, dosage, route, and the signature of the administering nurse, which was not followed in these instances.