Failure to Accurately Document and Witness Controlled Medication Administration and Wasting
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administration of medications for its residents. Specifically, during a controlled medication reconciliation, it was found that a nurse administered a Clonazepam tablet to a resident but did not document the administration in the clinical record at the time it occurred. The nurse confirmed the omission, and facility leadership acknowledged that all floor nurses were aware of the requirement to document narcotic administration promptly in the clinical record. Additionally, the facility did not follow proper procedures for wasting or destroying narcotic medications. In one instance, two Oxycodone/Acetaminophen tablets were documented as wasted after being dropped, but there was no evidence of a required witness or second signature for either event. The nurse involved confirmed the lack of a witness signature, and the DON verified that all nurses were expected to have a witness and document accordingly when wasting narcotics. These failures were observed on two separate medication carts and involved two different residents.