Deficiencies in Controlled Medication Administration, Documentation, and Disposal
Penalty
Summary
A deficiency occurred when a nurse administered hydrocodone-acetaminophen, a controlled medication prescribed for severe pain (pain level 8-10), to a resident who reported a pain level of 6, which is considered moderate pain. The medication was given outside the prescribed parameters on multiple occasions, as confirmed by a review of the Medication Administration Record (MAR) and interviews with the nurse and Director of Nursing (DON). The nurse acknowledged administering the medication for moderate pain and stated that physician orders should have been followed or clarified if the resident's pain level changed. Another deficiency was identified in the documentation and accountability of controlled substances. For a resident prescribed lorazepam oral concentrate, the facility's controlled drug record (CDR) did not accurately reflect the administration of the medication. The nurse admitted to administering the medication but failing to document it immediately on the CDR, which was confirmed by discrepancies between the medication container, CDR, and electronic medical record. The DON confirmed that immediate documentation is required to account for controlled medications and prevent errors. Additionally, the facility failed to ensure the proper disposal of discarded medications. Observations of two medication carts revealed red containers filled with tablets and capsules with open lids, making the medications retrievable and accessible. Nurses stated that these containers should have been emptied into the incineration bin and that leaving them accessible posed a risk for accidental exposure or misuse. Facility policy required that outdated or discarded medications be immediately removed and disposed of according to established procedures.