Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to accurately account for controlled medications and document shift-to-shift controlled medication counts for all seven residents reviewed for controlled medications. Facility policy requires that controlled medications be counted at the end of each shift by both the outgoing and incoming nurse, with documentation and reporting of discrepancies to the Director of Nursing (DON). However, observations revealed that controlled medication binders for multiple medication carts were missing required Controlled Substance Shift Change Count Sheets, and where forms were present, they often lacked two nurse signatures or had missing entries for specific dates. The DON confirmed that not all required forms could be located for the relevant months and that the process was not being followed as outlined in facility policy. Further review of medication administration records (MARs) and controlled drug receipt/record/disposition forms showed discrepancies in medication administration documentation. For example, one resident received Lorazepam without an active order in the electronic medical record, and doses were administered and signed out on controlled drug records but not on the MAR. Staff interviews revealed that medications were sometimes given based on verbal reports or hospice instructions without verifying active orders in the electronic record, and doses were not always documented on the MAR as required. In another case, a resident's Norco administration was not recorded on the MAR, despite being signed out on the controlled drug form, with staff citing power outages as a reason for not completing documentation. These findings demonstrate that the facility did not consistently follow its own policies for controlled medication management, including shift-to-shift counts, dual nurse verification, and accurate documentation of medication administration. The discrepancies between controlled drug records and MARs, as well as missing or incomplete count sheets, were confirmed by staff and the DON during the survey.