Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain accurate and complete records for controlled substances for four of six randomly selected residents. In one instance, nursing staff signed out a controlled medication from the Controlled Substance Accountability Sheet (CSAS) for a resident but did not document its administration on the Medication Administration Record (MAR). This discrepancy was confirmed by the Director of Nursing (DON) during a review of the records, where a dose of hydrocodone-acetaminophen was signed out but not recorded as administered on the MAR. In other cases, nursing staff documented the administration of controlled medications on the MAR for three residents but did not sign out the medications on the CSAS. For example, doses of hydrocodone-acetaminophen and tramadol were recorded as given on the MAR but were not reflected on the CSAS, indicating a lack of reconciliation between the two records. The DON confirmed that there were no additional CSAS records to account for these discrepancies and acknowledged that the medications were dispensed from the Automated Dispensing Unit (ADU), but the required documentation was not completed. Additionally, during a controlled substance count, a nurse confirmed that the physical count of a resident's medication did not match the CSAS, as one tablet was removed and administered but not signed out. The facility's policy requires that all controlled substances be properly documented on both the CSAS and MAR, and that inventory counts be reconciled at the end of each shift. These failures in documentation and reconciliation were observed and confirmed through interviews and record reviews.