Incomplete Medical Record for Controlled Drug Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of four sampled residents. Specifically, the surveyor requested the complete Controlled Drug Administration Record (CDAR)/Declining Sheet for a resident's medication, but the facility was unable to provide the entire documentation. The only available record was a single sheet with a specific date issued, and despite further requests and searches by the Director of Nursing, the full CDAR/Declining Sheet could not be located. An email response confirmed that the document was still missing at the time of the survey. This deficiency was identified through observations, interviews, and review of medical records and facility documentation. The resident involved had multiple diagnoses and was receiving medication as ordered, but the lack of a complete CDAR/Declining Sheet meant that the facility did not have a full record of the administration of a controlled drug as required by federal and state regulations.
Plan Of Correction
1. Resident #2 was discharged from the facility. 2. All residents who have orders for medications that require a Controlled Drug Administration Record/Declining Sheet have the ability to be affected by this practice. 3. The Medical Record staff was re-educated on the procedure for maintaining accurate, complete, readily accessible, and systematically organized records by the Director of Nursing or designee. The Drug Administration Record Declining sheet will be reviewed for accuracy and placed in residents' charts. 4. The Director of Nursing/Designee will audit the Controlled Drug Administration Record/Declining Sheet on each cart weekly x 4 and monthly x 2. The results of the audit will be reviewed at the Monthly Quality Assurance Meeting for three months. Continuation of the audits, reporting, and frequency after three months will be determined by the QA Committee.