Failure to Accurately Document and Account for Controlled Medication Administration
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting and administration of controlled medications for one resident. A review of the facility's policy on administering medications indicated that medications should be given according to prescriber orders and documented in the resident's medical record, including the date and time of administration. For one resident with a physician's order for Oxycodone 10 mg to be administered three times daily for back pain, discrepancies were found between the controlled substance record and the Medication Administration Record (MAR). Specifically, nursing staff signed out doses of Oxycodone on two separate dates and times in the controlled substance record, but there was no corresponding documentation in the MAR to indicate that the medication was actually administered to the resident at those times. The Nursing Home Administrator confirmed these discrepancies during an interview. The findings indicate a failure to accurately document and account for the administration of controlled substances as required by facility policy and state regulations.