Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate accounting and documentation of narcotic medication administration for a resident who was cognitively intact and dependent on staff for transfers following recent leg surgery. The resident was prescribed oxycodone for pain management, with orders changing from 5 mg to 10 mg tablets during the month. Review of the resident's Medication Administration Record (MAR) and Controlled Drug Declining Inventory Sheets revealed multiple discrepancies. Specifically, several doses of oxycodone were documented as administered on the inventory sheets but were not recorded on the MAR, and there were inconsistencies in the times of administration between the two records. The Director of Nursing confirmed these discrepancies upon review, acknowledging that staff are required to document administration in both the electronic record and the inventory sheet at the time of administration. Facility policy mandates immediate and accurate documentation of controlled substances, including date, time, amount administered, and nurse signature, in accordance with federal and state regulations. The observed failures included missing entries and mismatched times between records, resulting in an inability to accurately reconcile the receipt and disposition of controlled drugs for the resident.