Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. A review of the clinical records and controlled drug record for a cognitively intact resident receiving opioid medication revealed that several doses of Tramadol were signed out on specific dates and times. However, there was no documented evidence in the resident's clinical record, including the Medication Administration Record (MAR), to confirm that these doses were actually administered. This lack of documentation was confirmed by the Director of Nursing during an interview, indicating a failure to ensure accurate recordkeeping for controlled substances as required by regulations. The resident involved required assistance for care needs and had a physician's order for Tramadol to be given as needed for moderate to severe pain. Despite the medication being signed out, the absence of corresponding administration records led to the identified deficiency.