Failure to Document Controlled Drug Administration in Both CDR and MAR
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for two residents when controlled drug administrations were not properly documented in both the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For one resident with a history of femur fracture and muscle weakness, Norco was signed out from the CDR on three occasions, but these administrations were not recorded on the MAR. For another resident with Parkinson's disease, diabetic polyneuropathy, and muscle weakness, Norco was also signed out from the CDR on two occasions without corresponding documentation on the MAR. Both residents were assessed as having intact cognition at the time of the incidents. Interviews with nursing staff and facility leadership confirmed that the expected practice is to document controlled medication administration in both the CDR and MAR. Facility policy also requires this dual documentation. The discrepancies were identified during a random audit and were acknowledged by both the licensed nurse involved and the Director of Nursing, who described the correct process for administering and documenting controlled drugs. The failure to document these administrations in the MAR was directly observed and confirmed through record review and staff interviews.