Failure to Document Controlled Substance Administration per Professional Standards
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for one resident. Facility policy required that the Controlled Drug Record be signed by the nurse at the time the drug is given, and that administration be documented on the medication administration record (MAR). For a resident with quadriplegia and hypotension who had physician orders for oxycodone as needed for pain, review of records showed discrepancies between the controlled drug record and the MAR. Specifically, oxycodone was documented as being dispensed 17 times, but only 8 administrations were signed off on the MAR. Additionally, some administrations were recorded on the MAR either before or well after the medication was documented as dispensed, and several dispensed doses were not signed off on the MAR at all. Interviews with the DON, Assistant DON, and Nursing Home Administrator confirmed that staff are expected to document on both the controlled drug record and the MAR when administering controlled substances. However, they were unable to provide an explanation for the discrepancies or missing documentation. This failure to accurately document the administration of controlled substances did not comply with facility policy or professional standards of nursing practice.