Failure to Maintain Accurate Controlled Substance Records and Administration
Penalty
Summary
The facility failed to maintain accurate records and proper administration of controlled substances for four out of five residents reviewed. Multiple discrepancies were identified between the Electronic Medication Administration Record (eMAR) and the Controlled Substance Proof of Use forms, with several forms missing entirely for various narcotic medications, including fentanyl patches, hydrocodone-acetaminophen, oxycodone-acetaminophen, and morphine. Staff interviews revealed that documentation was often incomplete or not performed in a timely manner, particularly on the eMAR, and that the Proof of Use forms were not consistently filed or scanned into the residents' electronic medical records. For one resident with complex medical needs, including Parkinson's disease and chronic pain, there were lapses in the administration of fentanyl patches due to pharmacy delivery delays and errors in order entry, resulting in missed doses over several days. Additionally, the Proof of Use forms for hydrocodone-acetaminophen were missing, and the number of tablets administered did not consistently match the records. Staff admitted to not always documenting PRN medication administration on the eMAR, relying instead on the Proof of Use forms, which were also not reliably maintained or stored. Similar issues were found for other residents with orders for controlled substances. For example, one resident with pain and muscle spasm diagnoses had multiple deliveries of oxycodone-acetaminophen with missing Proof of Use forms and inconsistent documentation between the eMAR and inventory forms. Another resident with dementia and a history of falls had missing forms for morphine deliveries, and the number of doses administered did not align across records. The facility's policies required accurate documentation and inventory of controlled substances, but these procedures were not followed, leading to significant gaps in accountability and recordkeeping.