Failure to Ensure Accurate Documentation and Administration of Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to ensure proper administration and documentation of controlled substances for two residents. For one resident, the controlled drug administration record for Oxycodone showed five instances where the medication was signed out of the medication cart, but there was no corresponding documentation in the Medication Administration Record (MAR) to indicate that the medication was administered or that there was a documented need for it. The dates and times on the controlled drug record did not match the MAR, and this discrepancy was confirmed by the LPN present during the review. For another resident, the controlled drug administration record for Tramadol showed that while dates were documented for when the medication was removed, the times were missing. This lack of complete documentation was also confirmed by the LPN responsible for the medication cart. The Director of Nursing acknowledged that her expectation was for the controlled drug administration records to match exactly with the MAR, and she was made aware of these findings during the survey.