Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for two residents. Facility policy required that staff administering medications document the administration on the Medication Administration Record (MAR) immediately after giving the medication. For one resident, who was cognitively intact and receiving Tramadol for pain, the controlled drug record showed that multiple doses were signed out on specific dates and times, but there was no documentation in the clinical record or MAR to confirm that these doses were actually administered. This lack of documentation was confirmed by the Assistant Director of Nursing. Similarly, another resident, who was cognitively impaired with dementia and chronic pain syndrome and had orders for Tramadol as needed, had several doses signed out on the controlled drug record. However, there was no evidence in the clinical record that these doses were administered. The Assistant Director of Nursing also confirmed the absence of documentation for these administrations. These findings indicate that the facility did not ensure proper documentation and accountability for controlled substances as required by policy and regulation.