Failure to Accurately Document Controlled Substance Administration in MARs
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) accurately reflected the administration of controlled substances for four residents. For each resident, there were discrepancies between the controlled substance administration records and the MARs, with the MARs lacking documentation of administered medications on multiple dates and times. This included medications such as Oxycodone, Percocet, Lorazepam, and Morphine, which were documented as given in the controlled substance records but not recorded in the MARs as required by facility policy. Resident B, who had diagnoses including diabetes, chronic pain, and a gastrointestinal stromal tumor, was prescribed Oxycodone at specific intervals. The controlled substance record showed administration on several dates, but the MAR did not reflect these administrations. Similarly, Resident C, with a history of fractures, gout, and depression, was prescribed Percocet as needed for pain, and the controlled substance record indicated multiple administrations that were not documented in the MAR. Resident D, diagnosed with depression and chronic pain, also had Oxycodone administrations recorded in the controlled substance log but not in the MAR. Resident E, with conditions such as diaphragmatic hernia and low back pain, was prescribed Lorazepam for agitation and Morphine for pain. The controlled substance records indicated these medications were administered on several occasions, but the MARs lacked corresponding documentation. During an interview, a registered nurse confirmed that the MAR should be initialed by the nurse administering the medication, in accordance with facility policy. The facility's policy on controlled substances requires that all administrations be recorded in the MAR to prevent diversion and improper use.