Failure to Account for Controlled Substances Due to Incomplete Documentation
Penalty
Summary
The facility failed to properly account for two doses of controlled substances for two residents during a survey of one of the medication carts. For one resident with muscle weakness and surgical aftercare, a review of the Medication Administration Record (MAR) and the Individual Narcotic Record accountability log showed a missing dose of oxycodone 2.5 mg. The log indicated there should have been ten tablets remaining after the last documented administration, but only nine were present, with no documentation of further administrations. For another resident with epilepsy, a similar discrepancy was found with lacosamide 100 mg, where the log showed seven tablets should have been present, but only six were found, again with no documentation of additional administrations. During an interview and observation, the Licensed Vocational Nurse (LVN) responsible for administering these medications admitted to having given the doses earlier that day but failed to sign off on the Individual Narcotic Record accountability log as required by facility policy. The LVN acknowledged not following the policy of signing each controlled substance dose on the accountability log immediately after preparing the medication for administration. The LVN also recognized the importance of accurate documentation for accountability and prevention of controlled substance diversion and accidental exposure. The Director of Nursing (DON) confirmed that the LVN did not follow the facility's policy, which requires immediate documentation of controlled substance preparation and administration on the accountability records. A review of the facility's policy and procedures indicated that controlled substances must be handled, stored, and documented in accordance with federal and state regulations, including immediate entry of administration details on the accountability record by the administering nurse.