Failure to Properly Dispense and Document Controlled Medications
Penalty
Summary
The facility failed to ensure proper dispensing and documentation of controlled medications for three residents. For one resident with osteoporosis, tramadol was documented as dispensed on several dates, but the Medication Administration Record (MAR) showed it was not administered, and there was no documentation explaining the discrepancy. On another date, the MAR indicated the medication was administered, but there was no corresponding record of it being dispensed. The Director of Nursing confirmed a documentation error regarding the administration and disposal of the medication. Another resident with an anxiety disorder received a dose of alprazolam that was dispensed without an active physician order, and there was no documentation in the MAR or electronic medical record to support the administration or the existence of a one-time verbal order. For a third resident with anxiety disorder, lorazepam was dispensed on multiple occasions, but the MAR and electronic medical record lacked documentation of its administration. The facility's policy requires accurate accountability and documentation for all controlled substances, including when doses are administered, refused, or destroyed, but these procedures were not followed in the cited cases.