Failure to Document Administration and Disposal of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for three residents. Facility policy required that the administration of medication be documented by initialing the Medication Administration Record (MAR) after each dose, and that the disposal of controlled substances be witnessed and documented by two staff members. For one resident receiving a Fentanyl transdermal patch for pain management, there was no documented evidence that the removed patches were disposed of in the presence of a nurse and a witness as required by policy. This lack of documentation was confirmed by the Director of Nursing. Additionally, for two other residents prescribed Tramadol, a controlled opioid medication, the controlled drug accountability records showed that doses were signed out for administration, but there was no documented evidence in the clinical records that these doses were actually administered. The Director of Nursing confirmed the absence of documentation for the administration of these controlled drugs. These findings indicate that the facility did not follow its own policies for documenting the administration and disposal of controlled substances for these residents.