Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication. Review of the clinical record for a resident who was cognitively intact and receiving opioid medication for pain management revealed that multiple doses of Hydrocodone-Acetaminophen were signed out on the controlled drug record over several months. However, there was no documented evidence in the resident's clinical record, including the MAR, to confirm that these signed-out doses were actually administered to the resident on the specified dates and times. This lack of documentation was confirmed by the Director of Nursing, who acknowledged that the records did not show administration of the medication as required.