Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for seven out of twelve residents reviewed during a random audit. Specifically, medications were documented as administered on the Medication Administration Record (MAR) for several residents, but the corresponding doses were not signed out on the Controlled Drug Record (CDR). For example, a resident with a physician's order for Methadone had three tablets unaccounted for in the CDR, and the nurse confirmed that while the medication was documented in the MAR, it was not signed out in the CDR. Similar discrepancies were found for residents receiving Lorazepam and Hydrocodone-Acetaminophen, where the medications were recorded as given in the MAR but not reflected in the CDR. Conversely, there were instances where medications were signed out of the CDR but not documented as administered in the MAR. This occurred with residents prescribed Oxycodone, Tramadol, and other controlled substances. In these cases, nursing staff removed the medications from the locked controlled medication compartment, signed them out in the CDR, but failed to document the administration in the MAR. The Director of Nursing (DON) acknowledged that these controlled medications were not accounted for in the MAR during concurrent interviews and record reviews. A review of the facility's policies and procedures confirmed that staff are required to document the administration of medications immediately in both the MAR and the CDR. The observed failures to follow these procedures resulted in inaccurate accountability of controlled medications, as confirmed by staff interviews and record reviews during the survey.