Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for residents, specifically regarding the administration and documentation of controlled medications. For one resident, a review of the controlled medication utilization record showed that two doses of Oxycodone were signed out by licensed nursing staff, but only one dose was documented as administered in the medication administration record (MAR). The Director of Nursing confirmed that there was no nursing documentation for the remaining dose that was signed out. For another resident, the controlled medication utilization record indicated that ten doses of Oxycodone were signed out, but only three doses were documented as administered in the MAR. The Director of Nursing confirmed that there was no nursing documentation for the seven remaining doses that were signed out. These findings demonstrate a lack of a system to ensure that clinical records accurately reflect medication administration, as required by facility policy and professional standards.