Medication Availability and Controlled Substance Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident with multiple diagnoses, including dementia, unspecified psychosis, Parkinson's disease, and anxiety. The resident had a physician's order for Klonopin 0.5 mg to be administered twice daily, but the medication was not available from the pharmacy for several consecutive days. Nursing administration notes and interviews with nursing staff confirmed that the medication was not received and, therefore, not administered as ordered on multiple occasions. Additionally, the facility did not maintain accurate or complete records for controlled substances on two medication carts. Review of controlled substance count sheets for two residents revealed missing information, such as the date and time medications were received, inaccurate distribution amounts, incomplete on-hand amounts, and missing nurse signatures. There was also a lack of documented evidence for the receipt and disposition of controlled medications for these residents. Further review of the controlled drug inventory forms for both medication carts showed multiple instances where required shift change reconciliations were not completed or lacked the necessary signatures from both oncoming and off-going nurses. Interviews with nursing staff and the administrator confirmed that the controlled substance reconciliations were incomplete or inaccurate, and that the forms should have been properly completed and verified.