Failure to Accurately Record and Reconcile Controlled Drug Administration
Penalty
Summary
The facility failed to establish and maintain an adequate system for recording the receipt and disposition of controlled drugs, specifically Hydromorphone, for one resident. The resident expressed concern about receiving the wrong dose of pain medication. Review of the Medication Administration Records (MAR) and Individual Patient's Narcotic Records revealed multiple instances where the resident was administered an incorrect dose of Hydromorphone, including full 2 mg tablets instead of the prescribed 1 mg (0.5 tablet) dose. These errors were confirmed by the Director of Nursing during interviews. Additionally, there was a documented discrepancy in the quantity of Hydromorphone tablets received, with conflicting documentation by two nurses regarding the number of tablets accepted by the facility. The facility did not follow its own policy for managing controlled substances when the discrepancy was identified. The nursing supervisor was not notified, a Controlled Drug Discrepancy Investigation Form was not completed, and no investigation into the discrepancy was initiated. The facility's policy requires that any discrepancies in controlled drug receipt or administration be reported and investigated immediately, but this process was not followed in this case.