Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting and administration of controlled medications for one resident. According to facility policy, all controlled substances must be recorded on a designated usage form, and the dosage recorded must match the documentation in the Medication Administration Record (MAR) and be retained in the resident's medical record. For a resident admitted with diagnoses including vascular dementia, COPD, osteoporosis, and cerebral infarction, physician orders included Level 4 Comfort Care and administration of Morphine Sulfate Solution as needed for pain. The controlled substance record showed that nursing staff signed out doses of morphine on three occasions. However, there was no corresponding documentation in the MAR indicating that the medication was administered to the resident at those times. This discrepancy between the controlled substance record and the MAR demonstrates a failure to ensure accurate documentation and reconciliation of narcotic records, as required by facility policy. The Director of Nursing confirmed these discrepancies during an interview.