Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to facility policy, documentation of narcotic administration must be completed in accordance with applicable law, including recording necessary information on appropriate forms. For a resident with cognitive impairment and multiple diagnoses, including Parkinson's disease, stroke, and sarcopenia, physician orders required administration of oxycodone-acetaminophen as needed for pain. The controlled drug record indicated that doses of this medication were signed out on several occasions. However, review of the Medication Administration Record (MAR) revealed no documented evidence that the medication was actually administered to the resident on the dates and times listed in the controlled drug record. The Director of Nursing confirmed that there was no documentation of medication administration on the MAR for those dates and times, despite facility policy requiring such documentation.