Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
A deficiency occurred when a nurse failed to correctly document the administration of controlled medications for a resident. Specifically, the nurse left controlled medications unattended on top of a medication cart and incorrectly signed out three doses of lorazepam on the controlled drug record, while the actual medication card count did not match the documentation. Additionally, the nurse signed out doses of oxycodone on the medication administration record (MAR) but did not document the administration of lorazepam in the MAR, and a scheduled lorazepam dose was documented at a different time. There were also discrepancies in the narcotic count sheets for both lorazepam and oxycodone, with mismatched counts between the medication cards and the controlled drug records. Further review revealed that another nurse administered a dose of oxycodone but failed to sign it out on the controlled drug record. During shift changes and narcotic counts, discrepancies were noted, and requests to correct the narcotic records were not immediately addressed. The nurse responsible for the errors admitted to incorrectly signing out doses and not documenting medication administration in the MAR. These actions and inactions led to inaccurate records and discrepancies in the accountability of controlled substances for the resident.