Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that controlled medications were fully accounted for, as evidenced by discrepancies found during a random audit of controlled medication use for two out of four sampled residents. In both cases, nursing staff signed out controlled medications from the Controlled Drugs Records (CDR) but did not document the administration of these medications on the Electronic Medication Administration Record (eMAR). Specifically, for one resident with an order for Oxycodone 5 mg as needed for pain, the CDR indicated that doses were signed out on two occasions, but there was no corresponding documentation on the eMAR or in the nursing progress notes to confirm administration. For another resident with orders for Tramadol 25 mg and 50 mg as needed for pain, the CDR showed that doses were signed out on four occasions, but again, there was no documentation on the eMAR to indicate administration. Interviews with the Director of Nursing (DON) and a Licensed Nurse (LVN1) confirmed that the facility's process requires documentation of controlled medication administration on both the CDR and the eMAR. The DON and LVN1 verified that the required documentation was missing for the identified instances. Review of the facility's policy indicated that the licensed nurse is responsible for charting the date and time of each administered medication, including PRN medications, on the eMAR. The lack of documentation resulted in inaccurate accountability of controlled medications for the affected residents.