Failure to Accurately Dispense, Document, and Remove Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents, specifically in the accurate dispensing and administration of controlled substances. Surveyors observed that for several residents, there were discrepancies between the Medication Monitoring/Control Records and the Medication Administration Records (MAR). For example, medications such as Hydromorphone, Tramadol, Alprazolam, Fentanyl patches, and Percocet were signed out on the control records but not documented as administered on the MAR, or vice versa. In some cases, controlled medications that had been discontinued or were for residents no longer in the facility remained in the medication carts, contrary to facility policy and standard practice. Interviews with nursing staff and the DON revealed inconsistent practices regarding the handling and documentation of controlled substances. The DON stated that discontinued or unused controlled medications should be removed from the carts and stored securely until destroyed, with a log maintained of destroyed medications. However, LPNs reported that discontinued medications were sometimes left in the carts until someone collected them, and periodic audits of the carts were not consistently performed. Staff also acknowledged that there were instances where medications were signed out on the control record but not documented on the MAR, and vice versa. Record reviews for multiple residents showed that controlled substances were not always properly reconciled or documented. For example, one resident's Tramadol was signed out on the control record on several dates but not recorded as administered on the MAR. Another resident's Alprazolam, which had been discontinued months earlier, was still present in the cart and signed out on the control record without corresponding MAR documentation. Similar discrepancies were found for other residents, including missing documentation for administered doses and the presence of discontinued medications in the carts. These findings indicate a failure to maintain accurate records and ensure the secure handling of controlled substances for multiple residents.