Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of three medication carts, specifically regarding a resident who was prescribed Pregabalin 25 mg for neuropathic pain. During an inspection, it was found that the Controlled Drug Receipt/Record/Disposition Form (CDR) for this medication was inaccurate, as the number of tablets documented as administered did not match the actual count in the medication bubble pack. A licensed vocational nurse acknowledged that one dose was given to the resident but was not recorded on the CDR, although it was documented in the electronic medical record (EMR). Facility policy requires that all administered doses of controlled substances be documented both in the CDR and the EMR, and that the physical count of medication matches the records to prevent drug diversion. The Director of Nursing confirmed that the policy was not followed in this instance, as the nurse failed to document the administration of a controlled medication on the required CDR form, resulting in a discrepancy between the medication count and the documentation.