Failure to Accurately Account for and Administer Controlled Pain Medication
Penalty
Summary
The facility failed to ensure accurate accounting and administration of a controlled pain medication for one resident following hip replacement surgery. The resident, who was cognitively intact, had a physician's order for Tramadol 50 mg twice daily. On the evening in question, the Medication Administration Record (MAR) indicated that a nurse had documented administration of the medication, but the Controlled Drug receipt/Record/Disposition Form showed no Tramadol was removed from the resident's supply. Instead, the nurse had mistakenly removed Tramadol from another resident's supply and did not properly document the error or the actual recipient of the medication. The resident reported receiving the medication late that evening, while the nurse provided conflicting times for administration and inaccurately recorded the removal time on the other resident's controlled drug form. Further review revealed that the nurse did not follow proper procedures for documenting and reporting the medication error, including failing to notify a supervisor and obtain two signatures on the controlled drug forms as required. The documentation on both the MAR and the controlled drug forms did not match the actual events, leading to discrepancies in the records. Interviews with the Director of Nursing and the facility's Nurse Consultant confirmed that the documentation and handling of the controlled medication did not meet facility protocols for accuracy and accountability.