Failure to Immediately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality regarding the administration and documentation of controlled medications for two residents. According to facility policy, licensed nurses are required to immediately document the administration of controlled drugs on the narcotic accountability record, including the date, time, amount administered, and the nurse's signature, after the dose is given. However, during an observation of the North Medication Cart, discrepancies were found in the narcotic counts for two residents. The LPN responsible acknowledged that medications had been administered and signed off on the medication administration record (MAR), but had not yet documented them on the narcotic accountability record as required. For one resident with diagnoses of high blood pressure, anxiety, and depression, the clonazepam count was off by one pill, and for another resident with heart failure, high blood pressure, and anxiety, the lorazepam count was also off by one pill. In both cases, the narcotic accountability log did not match the actual number of pills present due to the LPN's failure to immediately document the administration. The Director of Nursing confirmed that the facility did not meet accepted standards of clinical practice for these two residents.