Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property by not maintaining effective processes to prevent the misappropriation of controlled substances. Specifically, for two residents with physician orders for scheduled doses of Oxycodone-based pain medications, discrepancies were found in the administration and documentation of these controlled substances. The controlled substance logs showed that more doses were signed out than prescribed, with some days reflecting up to 11 doses when only 4 were ordered. Additionally, the logs contained multiple instances of dates being scribbled out, written over, or entered out of order, making it difficult or impossible to accurately track medication administration. For one resident, pharmacy records indicated that 120 tablets of Oxycodone-APAP were delivered as a 30-day supply, but the medication was requested for refill eight days early. Upon review, it was found that the administration history did not match the expected dosing schedule, and the controlled substance logs were inconsistent and illegible in places. The count of tablets in the blister packs matched the documented end count, but the daily administration records showed more doses than prescribed, and missed doses were also documented. Similar issues were identified for another resident receiving Oxycodone, with the controlled substance logs again showing illegible entries and dates out of sequence. The facility's investigation revealed that these discrepancies were associated with an LPN, who admitted to changing dates on medication documents and could not account for multiple signatures. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The facility identified that the issues were not isolated to a single resident but affected multiple residents receiving controlled substances, and the documentation practices failed to ensure accurate and legible records of controlled substance administration.