Failure to Document Controlled Substance Administration on MAR
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substance (CS) medications for three of five residents reviewed. In each case, nursing staff signed out CS medications from the Controlled Drug Record (count sheet) but did not document the administration on the Medication Administration Record (MAR). For one resident, a tablet of hydrocodone-acetaminophen was signed out but not recorded on the MAR. For another, three instances were found where oxycodone-acetaminophen tablets were signed out on the count sheet but not documented on the MAR. A third resident had a similar discrepancy with a Norco tablet. In each instance, the responsible LVN acknowledged the missing documentation and confirmed that the medication should have been recorded on both the count sheet and the MAR immediately after administration. The Director of Nursing (DON) confirmed the expectation that CS medication administration must be documented on both the count sheet and the MAR, and acknowledged the discrepancies for the residents involved. Facility policies reviewed indicated that all controlled substances must be recorded on the designated usage form and that the dose recorded must match the MAR and the Controlled Drug Record. The lack of documentation resulted in inaccurate accountability of CS medications, as directly observed and confirmed by staff interviews and record reviews.