Failure to Document and Administer Controlled Medications per Policy
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to adhere to professional standards and facility policy regarding the administration and documentation of controlled substances during a specific overnight shift. The LPN did not document the removal of controlled medications on the Controlled Drug Records, despite recording their administration on the Electronic Medication Administration Record (EMAR). This discrepancy was identified for multiple residents, with missing signatures and unaccounted-for doses of medications such as Gabapentin, Phenobarbital, Tramadol, Percocet, Norco, and Lorazepam. In some cases, the LPN documented administration on the EMAR but did not sign the controlled drug record, while in other instances, medications were not administered or documented at all. The issue came to light after reports of the LPN's erratic behavior during the shift, which led to her removal from the facility by law enforcement. Subsequent medication counts and record reviews revealed multiple discrepancies, including missing doses and lack of proper documentation. Interviews with staff confirmed that the LPN was responsible for both administering and documenting the medications, and that the discrepancies were not identified until after the shift ended. The facility's policies required that all controlled substances be documented on both the MAR and the narcotic control record, with complete signatures and times, which was not followed in these instances. The affected residents had various medical conditions requiring controlled medications for pain, seizures, anxiety, and other diagnoses. The failure to properly document and administer these medications impacted at least nine residents and involved one of two medication carts on a specific hall. The investigation was initiated following a complaint and incident report, and the findings were corroborated by record reviews, staff interviews, and policy examination.