Controlled Substance Documentation and Physician Order Deficiencies
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled substance medications for four out of nine sampled residents, and did not obtain a physician order for a controlled medication for one resident. For one resident with dementia, schizoaffective disorder, and major depressive disorder, Lorazepam was administered after the physician's order had expired, and there was no current order in place. Additionally, discrepancies were found between the declining inventory sheet (DIS) and the Medication Administration Record (MAR), with some administrations recorded on the DIS but not on the MAR, and vice versa. For another resident with a history of nasal bone fracture and injury as a pedestrian, Percocet was administered with inconsistencies between the DIS and MAR, including documentation of administration at times that did not match between the two records. Similarly, a resident with osteomyelitis had Oxycodone administrations recorded on the DIS that did not correspond with entries on the MAR, and vice versa. These discrepancies were confirmed during interviews with nursing staff, who acknowledged that the DIS and MAR should correlate but did not in these cases. A fourth resident with cerebral infarction, spinal stenosis, and colon cancer also had inconsistencies in the documentation of Oxycodone administration. The narcotic sheet indicated a dose was removed and signed out by a nurse, but this administration was not documented on the MAR. Staff interviews confirmed that every removal of a controlled substance should be documented on both the narcotic sheet and the MAR with matching details, but this was not consistently done.