Deficient Controlled Substance Documentation and Improper Medication Administration
Penalty
Summary
The facility failed to maintain an accurate and detailed system for recording the receipt and disposition of controlled drugs, resulting in discrepancies that affected multiple residents. Staff did not consistently sign out medications on narcotic count sheets at the time of administration, as required by facility policy. There were instances where medications were either not given but signed out, or given without proper documentation, leading to inaccurate narcotic counts. For example, staff failed to sign out Lorazepam and Clonazepam for two residents, and in other cases, extra doses of oxycodone and tramadol were administered due to medications being prepped in advance and confusion among nursing staff. A review of a narcotic diversion incident revealed that controlled medications were documented as administered to several residents, including one who was hospitalized at the time, but the medications were not actually given. Law enforcement was involved after missing narcotics were discovered in a staff member's possession. Observations and interviews further revealed ongoing issues with the medication administration process. A nurse was observed signing out narcotics in the count book before actually administering the medication, resulting in discrepancies between the physical count and the documentation. The nurse admitted to not following the correct process due to being busy and acknowledged the error. Review of narcotic sign out sheets showed missing signatures for shift changes, indicating lapses in the required double-checking process for controlled substances. The Director of Nursing confirmed that staff continued to have difficulties following the correct procedures for narcotic counts and documentation, despite previous education efforts. Additionally, there were issues with delegation and documentation of medication administration. An LPN delegated the administration of medications to a Trained Medication Aide (TMA) who was acting as a CNA, after preparing the medications in advance. The LPN did not accompany the TMA into resident rooms and later documented in the Medication Administration Record (MAR) that the LPN had administered the medications, rather than the TMA who actually did so. Both the LPN and the Director of Nursing acknowledged that this was not in accordance with facility policy, as the person administering the medication should be the one to document it. These practices resulted in inaccurate records and a failure to ensure medications were administered according to professional standards.