Failure to Document Controlled Medication Administration and Improper Medication Handling
Penalty
Summary
Licensed nursing staff failed to document the administration of controlled pain medications, including the resident's pain level and the effectiveness of the medication, as required by professional standards. For multiple residents with chronic pain and cognitive impairments, controlled substances such as Oxycodone and Tramadol were signed out on the controlled substance disposition record and administered, but these administrations were not recorded on the Medication Administration Record (MAR) or in the nurse's notes. Pain assessments often indicated a pain level of zero prior to administration, and there was no documentation of complaints of pain, the administration itself, or the medication's effectiveness in the clinical record. Interviews with the LPN responsible for these administrations revealed that omissions in documentation were oversights, and the EMR system was designed to prompt for effectiveness documentation, which was not completed. Additionally, the facility failed to ensure that controlled medications for pain and anxiety were available for residents as ordered, resulting in staff borrowing medications from other residents' supplies. Controlled Substance Disposition Records showed multiple instances where medications were removed from one resident's supply and given to another, without documentation of physician orders authorizing this practice. Interviews with nursing staff and the DNS confirmed that borrowing medications occurred due to limited access to the automated medication dispensing system and staffing limitations, and that this practice was recognized as poor and not in line with facility policy or pharmacy consultant recommendations. Furthermore, a resident who did not wish to self-administer medications was observed with unsupervised medications left at the bedside by an LPN, who admitted to leaving medications with the resident upon request and without a physician's order. The facility's policy prohibits leaving medications unattended and requires staff to observe residents consuming their medications. The DNS confirmed that leaving medications at the bedside for unsupervised self-administration is unacceptable practice.