Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for two residents. For one resident who was cognitively intact and required assistance with care needs, there were multiple instances where doses of Oxycodone HCL were signed out on the controlled drug record, but there was no documented evidence in the clinical record or Medication Administration Record (MAR) that these doses were actually administered. This lack of documentation was confirmed by the Assistant Director of Nursing, who acknowledged the absence of records indicating administration of the signed-out doses. For another resident with cognitive impairment and a history of dysphagia following a stroke, physician orders required the application of a Fentanyl patch every three days. Although the MAR and controlled drug count record showed that the patches were applied as ordered, there was no documented evidence that two staff members signed for the destruction of the old patches after removal, as required by facility policy. The Director of Nursing confirmed that she was unaware of the requirement for two nurse signatures for the destruction of Fentanyl patches and acknowledged the lack of witness signatures for the relevant dates.