Failure to Accurately Document and Administer Controlled Medications per Physician Orders
Penalty
Summary
The facility failed to maintain accurate records and proper administration of controlled medications, as well as to follow physician orders for medication administration. During review of controlled drug administration record sheets, it was observed that nurses did not consistently sign out controlled medications after administration, resulting in discrepancies in medication counts for several residents. In one instance, a nurse admitted to giving medications but forgetting to document them in the controlled drug administration record. Additionally, a nurse was observed preparing and administering a different dosage of cranberry supplement than what was ordered, due to unavailability of the prescribed strength, without a corresponding physician order. Multiple staff members acknowledged that medication administration should follow physician orders and that documentation should occur immediately after medication is removed from the medication card or packet. Further observations revealed lapses in medication security, including an unlocked medication cart with keys left on top and the medication administration record (MAR) computer screen left open and unattended. Staff confirmed that these actions were not in accordance with facility policy. The facility's own policies require accurate and immediate documentation of controlled medication administration and strict adherence to physician orders, but these procedures were not followed as evidenced by the findings.