Failure to Accurately Document and Monitor Controlled Substance Administration
Penalty
Summary
The facility failed to accurately document and monitor the use of controlled substances for a resident who was prescribed both scheduled and PRN oxycodone for pain management. The Controlled Drug Count Record (CDCR) did not match the Medication Administration Record (MAR), with discrepancies in the number of tablets administered and recorded. Specifically, the pharmacy delivered a total of 106 oxycodone tablets, but the MAR showed 85 administrations while the CDAR indicated 105 tablets had been administered. Additionally, the CDCR was missing required signatures on several dates, and staff reported that both scheduled and PRN doses were being tracked on the same sheet, contrary to facility policy, which required separate sheets for each prescription. The resident involved had multiple diagnoses, including anemia, renal insufficiency, pneumonia, cellulitis, and pressure ulcers, and was dependent on staff for toileting and transfers. The care plan indicated ongoing pain related to wounds, and the resident reported experiencing pain and delays in receiving medication. Staff interviews confirmed inconsistencies in the documentation and counting process for controlled substances, and policy review revealed that the facility was not following its own procedures for controlled substance documentation.