Failure to Accurately Document Controlled Medications and Prohibit Pre-Pouring
Penalty
Summary
The facility failed to ensure an accurate count of controlled medications and did not adhere to its policy prohibiting the pre-pouring of medications. During an observation of a medication cart with an LPN, pre-poured medications were found in a plastic medication cup inside both the top drawer and the controlled/narcotic drawer. The LPN stated that the medications were prepared for two residents but had not yet been administered, as she was interrupted by another resident's call light. The LPN acknowledged that medications should be administered immediately after preparation and that pre-pouring is not permitted. A review and count of controlled medications revealed discrepancies between the actual number of tablets present and the number documented on the controlled drug administration record for two residents. Specifically, the count for Tramadol 50mg and Alprazolam 0.25mg did not match the documentation, with the LPN admitting she forgot to sign the date, time, and amount on the controlled administration record after removing the medications. The facility was unable to provide a medication policy specifically prohibiting pre-pouring, though their existing policies require accurate controlled medication counts and adherence to medication pass procedures.