Failure to Maintain Accurate Controlled Substance Records and Procedures
Penalty
Summary
The facility failed to maintain accurate records and procedures for controlled substances, specifically lorazepam and morphine, for one resident. The medication administration record showed that lorazepam was to be administered as needed, and the controlled drug count sheet indicated a discrepancy of 4 ml, with the count being corrected from 28.0 ml to 24.0 ml by two nurses. One nurse stated she noticed the discrepancy during the shift count and signed off on the correction, believing the other nurse would report it, but was unaware of what happened to the missing medication. The Assistant Director of Nursing confirmed that the nurse should not have signed off on the count and should have notified a nurse manager, and was not aware of the discrepancy until it was brought to her attention during the survey. Additionally, the physical bottle of lorazepam had unclear graduation marks, making it difficult for staff to accurately measure the remaining medication. For the same resident, the morphine count sheet showed a dose was documented as given without a date, time, amount left, or nurse signature. The nurse on duty stated she had not dispensed any morphine and that discrepancies should be reported to administration. The Assistant Director of Nursing was not aware of the incomplete documentation and stated it should have been identified and addressed at shift change. The facility's policy required controlled substances to be counted at each shift change, with discrepancies reported to the Director of Nursing or designee, and for the outgoing nurse to remain until the issue was resolved.