Failure to Maintain Accurate Controlled Drug Records and Documentation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled drugs was kept for one resident. The resident, who had a history of joint replacement surgery and Alzheimer's disease with dementia, was prescribed Hydrocodone-Acetaminophen for pain management. Review of the medical administration record (MAR) and the controlled drug receipt/record/disposition form revealed discrepancies: two tablets were pulled and administered on one day as documented, but on the following day, an additional tablet was pulled from the cart without corresponding documentation of administration in the MAR. There was no indication that any of the tablets were wasted. Interviews with nursing staff and the Director of Nursing confirmed that the expected process is to document the removal of narcotics from the cart on the narcotic count sheets and to record administration in the MAR. The LPN involved reported administering the medication at the request of the family but failed to document this in the MAR. The Director of Nursing acknowledged the lack of documentation and stated that this omission prevents staff from knowing what was administered to the resident. Facility policy requires accurate preparation, administration, and documentation of all medications once administered.