Significant Medication Errors in Controlled Substance Administration and Documentation
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically regarding the administration and documentation of controlled substances for seven residents. The facility's own Controlled Substance/Narcotic Management Protocol required accurate prescribing, administration, storage, destruction, and documentation of all controlled substances, including dual documentation in both the controlled substance logbook and the electronic medication administration record (eMAR). However, multiple instances were found where the documentation on the controlled medication record was inconsistent with the eMAR, and medications were administered at incorrect times or without proper physician orders. For example, one resident with anxiety and depression received Clonazepam at the wrong time of day on several occasions, with the medication being administered in the morning instead of at bedtime as ordered. The medication was signed out on the narcotic sheet but not properly documented in the eMAR, and the nurse responsible did not have a physician order for those administrations. Another resident with schizophrenia and anxiety received Clonazepam and Tramadol with similar inconsistencies, including doses given outside the prescribed schedule, undocumented administrations, and lack of required witness signatures for wasted medications. In some cases, medications were administered when there was no active physician order, and the records between the controlled substance log and the eMAR did not match. Additional deficiencies were noted with the administration of Oxycodone for pain management, where doses were given and documented on the controlled medication record but not reflected in the eMAR, and vice versa. There were also instances where a resident was told they had received medication when they had not, according to their own account and therapy schedule. Interviews with nursing staff and administration confirmed awareness of these discrepancies, and staff described the required procedures for documentation and witnessing of controlled substance administration and wastage, which were not consistently followed in practice.