Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for one resident, as evidenced by multiple discrepancies between the Medication Administration Records (MARs) and the corresponding Controlled Substance (CS) records. The resident in question had diagnoses including fibromyalgia, cerebral atherosclerosis, and unspecified dementia with agitation, and was receiving both scheduled and PRN opioid pain medications. The MARs indicated that medications such as Hydrocodone-Acetaminophen and Morphine Sulfate were administered at scheduled times, but these administrations were not consistently documented on the CS forms as required. Specific instances were identified where the MAR showed that doses were given, but there was no corresponding entry on the CS form, nor any documentation of refusal or explanation in the progress notes. For example, doses of Hydrocodone-Acetaminophen and Morphine Sulfate were marked as administered on the MAR but were missing from the CS records on several dates. In some cases, the CS forms reflected different administration times or omitted doses entirely, and in other cases, doses were documented as held on the MAR but still recorded as removed on the CS form. During an interview, the Director of Nursing acknowledged awareness of issues with controlled substance documentation and described a process of auditing CS forms for missing entries, but not for discrepancies between the MAR and CS forms. Facility policy required that controlled substance inventory be regularly reconciled with the MAR and documented accordingly, but this was not consistently followed, resulting in incomplete and inaccurate records for controlled substance administration.