Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for a resident admitted for a five-day hospice respite stay. The resident, who had multiple complex diagnoses including palliative care, multiple sclerosis, and seizures, had orders for controlled substances such as liquid morphine and lorazepam for pain and anxiety. Review of the Medication Administration Records (MARs) showed no documentation of administration for these medications, despite controlled substance proof of use records indicating that doses were removed from inventory. Controlled substance records showed multiple entries for removal of lorazepam and morphine, with some entries initialed by a nurse and others with illegible or unidentifiable initials. Several entries for morphine were later marked as errors and corrected, but there was no documentation of medication being wasted or administered, and the MARs remained blank. Progress notes and vital signs did not indicate the resident experienced pain or anxiety that would correspond with the medication removals, and there was no explanation in the clinical record for the discrepancies. Interviews with facility staff, including the DON and unit manager, revealed they were unable to explain the discrepancies or identify all staff involved in the documentation. The facility's policy required nurses to document both the removal and administration of controlled substances, but this was not followed. Attempts to contact the nurse responsible for the entries were unsuccessful, and staff acknowledged concerns with the documentation but could not provide further clarification.