Failure to Accurately Document Controlled Drug Reconciliation
Penalty
Summary
The facility failed to ensure the accuracy of medication reconciliation documentation for a controlled drug prescribed to a resident. According to the controlled drug administration record, thirty morphine capsules were received from the pharmacy. Subsequently, one capsule was administered to the resident, and the record indicated that twenty-nine capsules remained. However, the record later showed that twenty-four capsules were destroyed, which did not account for five capsules, resulting in a discrepancy. There was no documentation or clarification in the clinical or drug administration records to explain the missing five capsules. Interviews with facility staff, including the LPN and RN involved, revealed that neither could account for the five-capsule deficit. The LPN confirmed witnessing the destruction of the medications but did not recall any error, while the RN suggested the discrepancy might be a typographical error. The Chief Nursing Officer also acknowledged the discrepancy and referred to it as a clerical error. The issue was reviewed with facility leadership during the exit conference.