Failure to Remove Discontinued Controlled Medications and Inconsistent Documentation
Penalty
Summary
The facility failed to ensure proper management of controlled medications for three residents, resulting in discontinued medications remaining on medication carts and inconsistencies in medication administration documentation. For one resident with severe cognitive impairment, Lorazepam was administered multiple times after the physician had ordered it discontinued, and the medication remained accessible on the cart. Documentation on the narcotic sheet and medication administration record (MAR) did not consistently match, with missing times and unexplained signatures. The Director of Nursing acknowledged responsibility for ensuring discontinued medications are removed but confirmed that the process was not followed. Another resident with impaired cognition received Lorazepam after the discontinuation date, with narcotic sheets showing administration and removal from the medication card, but no corresponding documentation on the MAR. Staff interviewed were unable to identify who signed for the medication. A third resident with cognitive impairment received Oxycodone-Acetaminophen, but the administration times recorded on the MAR and narcotic sheet did not match, and staff could not clarify the discrepancies in signatures. These findings were based on observation, interview, and record review.