Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication. For a resident who was cognitively intact and required assistance with daily care, physician orders specified the administration of 50 mg of Tramadol every six hours for pain. Review of the resident's MAR for a specific month showed that several doses of Tramadol were signed out for administration on multiple dates. However, there was no documented evidence in the MAR or clinical record that these doses were actually administered to the resident on those dates. This lack of documentation was confirmed by the Quality Assurance and Performance Improvement Registered Nurse during an interview. The deficiency was cited under the relevant state pharmacy and nursing services regulations.