Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to establish and maintain a system for the accurate receipt and disposition of controlled drugs, specifically Lorazepam, for one resident. Review of the controlled medication count sheet showed that Lorazepam tablets were signed out on multiple occasions, but there was no corresponding documentation on the Medication Administration Records (MARs) or in the nurse notes to indicate that the medication was actually administered to the resident. The controlled medication count sheet also did not indicate that any doses were wasted. Interviews with nursing staff and facility leadership confirmed that they could not verify administration of the medication based on available records, and acknowledged the discrepancy between the count sheet and the MARs. The resident involved was an older female with diagnoses including acute respiratory failure, generalized anxiety disorder, and autistic disorder. She had significant cognitive impairment and communication difficulties, as documented in her Minimum Data Set (MDS). At the time of observation, the resident was calm and unable to answer questions appropriately. The facility's policy required staff to document medication administration on the MAR immediately after giving each medication, but this was not followed in the instances identified, resulting in incomplete and inaccurate records for controlled substances.