Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and reconciliation of controlled medication administration for four out of six residents reviewed. For one resident with chronic pain and multiple diagnoses, discrepancies were found between the electronic medication administration record (eMAR), the narcotic sign-out sheet, and the physical count of oxycodone tablets. Documentation showed doses being administered at times inconsistent with the schedule, missing signatures, and mismatched tablet counts. Interviews revealed confusion among staff regarding medication administration times and the number of tablets given, with one resident reporting having received two tablets early, though unable to recall specifics during a follow-up interview. Another resident with chronic pain and significant physical disabilities had inconsistencies between the eMAR and the narcotic sheet, including doses marked as not given and missing documentation for certain time slots. For a third resident with COPD and chronic pain, the eMAR and narcotic count sheet showed doses administered at incorrect times and uncertainty among staff about who administered the medication. One LPN admitted to removing medication from the card and having another staff member administer it, which was acknowledged as inappropriate. A fourth resident with a history of opioid use and chronic pain had doses signed out on the narcotic count sheet that were not reconciled with the eMAR, and no medication reconciliation was performed for several doses. Facility policies required physical inventory and reconciliation of controlled medications at each shift change, immediate documentation of administration, and reporting of discrepancies to the DON. However, these procedures were not consistently followed, leading to unaccounted-for medication doses and incomplete records.