Failure to Maintain Accurate Controlled Substance Records
Penalty
Fine: $54,438
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate and complete records for controlled substances, specifically hydrocodone, for a resident who had an order for Hydrocodone 5-325 mg by mouth every 6 hours for pain. On review of the medication administration record (MAR) and the controlled substance log for March and April, it was found that on one occasion, a nurse signed out a dose of hydrocodone but did not initial its administration on the MAR. Additionally, between two documented doses, two hydrocodone pills were removed and deducted from the count, but the nurse did not sign, date, or time these withdrawals on the controlled substance log as required. These discrepancies were confirmed by a corporate registered nurse during the survey.