Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of a controlled substance for one resident. The Controlled Substance Proof of Use form for a bottle of Lorazepam showed that one tablet was removed, but there was no time recorded or signature from the person who administered it. The next documented administration was later that same day, with the appropriate signature and time. The resident's Medication Administration Record (MAR) did not show a corresponding administration for the undocumented dose, and staff interviews revealed confusion about who administered the medication and when. One LPN stated that she might have given another dose in the morning, but the count in the bottle did not match the documentation. Another LPN stated she did not administer the medication during her shift and described how the count and documentation were reconciled after the discrepancy was discovered. The facility's policy requires that all controlled substances removed from the medication cart or cabinet be recorded on the designated usage form with clear and complete documentation. In this instance, the required documentation was incomplete, with missing time and signature for the administration of Lorazepam. Staff interviews confirmed that the documentation was not completed at the time of administration, and the process for reconciling the medication count was not followed as per policy.