Failure to Document Medication Administration and Maintain Controlled Substance Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including ALS, anxiety disorder, chronic pain syndrome, schizoaffective disorder, bipolar disorder, and adult failure to thrive. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Physician orders were in place for several controlled substances, including lorazepam, methadone, and morphine sulfate, with specific administration times documented in the resident's order summary report. On multiple occasions, staff did not sign the electronic Medication Administration Record (eMAR) to indicate whether medications were administered or refused. Specifically, there were blanks on the eMAR for scheduled doses of lorazepam, methadone, and morphine sulfate. Progress notes indicated that the resident refused some medications, but these refusals were not properly documented on the eMAR as required by facility policy. Interviews with the LPN/Unit Manager and the DON confirmed that the nurse responsible for medication administration did not follow the facility's documentation policy, resulting in missing signatures and incomplete records. Additionally, the facility was unable to provide the Individual Patient Controlled Substance Administration Record sheets for the resident's controlled medications for certain dates when requested by the surveyor. The DON acknowledged that these records should have been available and that the facility failed to adhere to its own policies regarding medication administration and documentation. Facility policies required all assessments, observations, and services to be documented in the medical record, and for refusals to be reported and documented, which was not done in this case.