Failure to Maintain Proper Controls and Documentation for Narcotic Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality regarding the control and documentation of narcotic medications for three residents reviewed for medication administration. Clinical record and facility documentation reviews revealed that staff signed out Hydromorphone on the Controlled Substance Distribution Record (CSDR) for multiple dates, but there was no corresponding documentation in the residents' medical records or Medication Administration Records (MAR) to confirm that the medication was actually administered. In some instances, narcotic medications were signed out on the CSDR when there were no physician orders, and there was a lack of required witness signatures for medication wastage. The Director of Nursing (DON) was unable to explain these discrepancies or provide documentation of the required monthly or bi-monthly audits of controlled substances for the relevant months, as stipulated by facility policy. Further investigation found that completed CSDR sheets were stored in the medical records office, but there was no evidence of audit results or documentation of audits being completed. Interviews with the DON and Administrator indicated that there was no established process or tracking system for current audits of controlled medications, and the DON could not explain how previous audits were conducted or why issues were not identified. The facility's Controlled Substance Handling Policy required monthly audits to monitor for discrepancies, unexplained wastage, and patterns of high usage, as well as the retention of accountability and audit records for at least five years, but these requirements were not met.