Failure to Document Administration of Controlled Medication
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. According to the facility's policy, staff are required to document medication administration on the Medication Administration Record (MAR). For one resident with a physician's order for Oxycontin 10 mg every four hours as needed, the controlled drug records showed that doses were signed out for administration on several dates. However, there was no documented evidence in the resident's clinical record or MAR that the Oxycontin was actually administered on those occasions. This was confirmed by the Assistant Director of Nursing during an interview, who acknowledged the lack of documentation for the administration of the medication.