Failure to Maintain Accurate and Complete Controlled Drug Records
Penalty
Summary
The facility failed to ensure and maintain accurate and complete drug records for multiple residents, as evidenced by discrepancies between controlled drug records, medication administration records (MAR), and physician orders. For one resident with Alzheimer's dementia and anxiety, Ativan was removed from secured storage and signed out by a nurse after the order had been discontinued, with no documentation in the MAR or medical record indicating administration or a valid order. Additionally, for the same resident, Norco was documented as administered in the MAR, but the controlled drug record indicated it was not given, as the count remained accurate. Another resident with paraplegia and chronic pain had Oxycodone signed out from secured storage after the order had expired, with no documentation in the MAR or medical record to support administration or a valid order. For a resident admitted to hospice with a history of cerebral infarction, the controlled drug record for morphine sulfate did not include the drug name or directions for use, and there were inconsistencies between the controlled drug record and the MAR regarding the times and documentation of administration. A further resident with toxic encephalopathy had Hydrocodone-Acetaminophen signed out twice on the same day, with a handwritten note indicating the medication was wasted, but without the required second nurse signature to verify the waste. The MAR indicated the medication was administered, but the documentation did not meet policy requirements. The facility's policy requires immediate and complete documentation of controlled substance administration and proper witnessing and documentation of wasted doses, which was not followed in these cases.