Failure to Accurately Document Administration of Controlled Substances
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication and before giving the next, and to maintain an individual controlled substance record for each resident receiving such medications. For one resident with a diagnosis including lumbosacral disc displacement and an order for Dilaudid 2 mg every six hours as needed for severe pain, the controlled drug record showed that doses of Dilaudid were signed out on three separate occasions. However, there was no documented evidence in the resident's MAR that these doses were actually administered on the dates in question. This discrepancy was confirmed by the Director of Nursing, who acknowledged the lack of documentation to indicate that the resident received the signed-out doses. The findings indicate a failure to follow facility policy and regulatory requirements for the administration and documentation of controlled substances.