Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to ensure that drug records for controlled substances were maintained in a manner that allowed for reconciliation between dispensed and administered medications. During a review of medical records and controlled medication count sheets for two residents, multiple discrepancies were identified. For one resident prescribed Lorazepam 0.5 mg as needed for anxiety, the count sheet indicated doses were administered on two occasions, but there was no corresponding documentation in the Medication Administration Record (MAR). For another resident admitted for recovery from a pelvic fracture and prescribed Oxycodone for pain management, the count sheet documented several administrations of both 5 mg and 10 mg doses, but these were not reflected in the MAR, and in one instance, the timing and dosage could not be reconciled between the two records. Interviews with an LPN and the Director of Nursing confirmed that facility policy requires controlled medication administrations to be documented accurately and consistently on both the count sheet and the MAR. The discrepancies found during the survey indicated that this process was not followed, as the records for the administration of controlled substances could not be reconciled, leading to a deficiency in pharmaceutical services for the residents involved.