Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property by not maintaining effective processes to prevent the misappropriation of controlled substances for two residents. For one resident, a physician's order specified a controlled substance to be administered four times daily, but pharmacy records and controlled substance logs revealed that the medication was being signed out and documented as administered more frequently than prescribed, with some days showing up to 11 doses. The controlled substance logs were found to have multiple dates scribbled over or written illegibly, making it difficult to determine the actual administration times and dates. Despite the discrepancies, the physical count of medication matched the expected amount, but the documentation did not align with the prescribed administration schedule. A similar issue was identified for another resident, where the controlled substance record of use also showed illegible and out-of-order dates, and the number of tablets signed out did not match the administration history. The logs indicated that more tablets were being signed out than were actually administered according to the administration history, and the documentation was inconsistent and unclear. The facility's investigation found that these discrepancies were associated with a specific LPN, who admitted to changing dates on medication documents and could not account for multiple signatures or events on the medication cart. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The deficiencies were discovered when the pharmacy consultant identified that a refill request for a controlled substance was made earlier than expected, prompting an audit of the controlled substance records. The audit revealed that the documentation did not accurately reflect the administration of medication as ordered by the physician, and the logs were not maintained in a legible or orderly manner. The facility's own investigation confirmed the documentation issues and linked them to the actions of the LPN involved.