Failure to Document Administration of Controlled Medications
Penalty
Summary
Nursing staff failed to accurately document the administration of controlled medications for three out of seven sampled residents. In each case, staff signed out controlled medications such as hydrocodone-acetaminophen and oxycodone from the Controlled Drugs Records (CDR), but did not record the administration on the Medication Administration Record (MAR). This discrepancy was identified during a review of the CDRs and MARs for residents who had physician orders for as-needed (PRN) narcotic pain medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the medications were signed out but not documented as administered on the MAR, and acknowledged that this documentation was required by facility policy. The facility's policies require that nursing staff sign the MAR after administering medications and maintain accurate controlled substance records, including the date, time, and signature of the person administering the medication. The DON stated that staff sometimes become busy and forget to document on the MAR, but confirmed that all controlled medications must be accounted for on the MAR. The failure to document these administrations resulted in inaccurate accountability of controlled substances for the affected residents.