Failure to Maintain Complete Controlled Drug Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate controlled drug records for several residents who were prescribed and administered controlled substances, such as hydrocodone-acetaminophen and oxycodone-acetaminophen, for pain management. For one resident, there were multiple periods where the controlled drug records were missing, despite documentation on the Medication Administration Record (MAR) indicating that the medications had been administered during those times. Specifically, there were no controlled drug records for certain periods, even though the MAR showed that doses were given, resulting in a lack of documentation to track the use of these controlled substances. Another resident's controlled drug record for oxycodone-acetaminophen was found to have missing pages, and the Director of Nursing (DON) confirmed that the facility was expected to keep all controlled drug records for narcotic medications but was unaware of the missing records until requested by surveyors. Similarly, for another resident, the controlled drug record for oxycodone was missing pages for a specified period, which was also acknowledged by the DON during an interview. In addition, for a fourth resident, staff failed to document the administration of oxycodone on the controlled drug record, even though the MAR indicated that the medication had been given on specific dates and times. The DON confirmed during interviews that staff were expected to document each administration of controlled medications on both the controlled drug record and the MAR, and that completed records should be retained and scanned into the resident's medical record. The absence of these records prevented reconciliation of the medications administered with the MARs and resulted in incomplete documentation for the acquisition, administration, and disposal of controlled substances for multiple residents.