Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for one resident by not ensuring proper reconciliation and documentation of a controlled medication, hydrocodone-acetaminophen. According to the facility's policy, licensed nurses are required to document the administration of controlled medications both on the accountability record and the Medication Administration Record (MAR) at the time of administration. For one resident, the Individual Narcotic Record showed multiple instances where hydrocodone-acetaminophen was signed out and presumably administered, but there was no corresponding documentation on the electronic MAR for those dates. This discrepancy was confirmed during a medication reconciliation conducted with a licensed vocational nurse (LVN), who acknowledged the lack of documentation on the MAR due to personal habit. Interviews with the resident confirmed that pain medication was received as requested, and the DON verified that the correct process requires documentation on both the controlled medication log and the MAR. The failure to document the administration of controlled medications as required by facility policy was acknowledged by both the DON and the Administrator. This lapse in documentation created a risk for improper medication reconciliation and potential diversion of controlled substances.