Failure to Accurately Document Controlled Medications and Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for four residents, resulting in inaccurate administration and documentation of medications. For one resident, there were discrepancies between the removal of controlled substances (oxycodone 10 mg and 15 mg) from the controlled drug record and the documentation in the Medication Administration Record (MAR). Specifically, the controlled medications were removed at certain times, but there was no corresponding documentation in the MAR to confirm administration. The Director of Nursing (DON) confirmed that licensed nurses are required to document both the removal and administration of narcotic medications, but this was not done for the identified instances. Additionally, three residents receiving insulin therapy did not have their injection sites rotated as required by facility policy and physician orders. Medical record reviews showed repeated administration of insulin at the same anatomical sites over multiple dates, with no documentation indicating that residents refused site rotation or that risks and benefits were explained to them. Interviews with nursing staff and the DON confirmed that injection sites should be rotated to prevent complications, and that the MAR should be checked to determine the last site used. However, this practice was not consistently followed, and there was no documentation of resident preference or education regarding site rotation. The facility's policies require accurate documentation of controlled substances and proper rotation of injection sites for subcutaneous medications. Despite these policies, the observed failures in documentation and administration practices were verified by nursing staff and facility leadership during interviews and record reviews. These deficiencies were acknowledged by the Administrator and DON.