Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that drug records were accurately maintained and that an account of all controlled drugs was periodically reconciled for a resident receiving Hydromorphone, a Schedule II controlled substance. Record reviews revealed discrepancies between the narcotic reconciliation log and the Medication Administration Record (MAR), including missing signatures, doses signed out on the reconciliation log but not documented on the MAR, and doses administered but not signed out or documented. Specifically, there were instances where multiple 1mL doses of Hydromorphone were either not recorded on the MAR or not signed out on the reconciliation log, resulting in an 18mL discrepancy in the medication count. The resident involved was a female with a history of cerebral infarction, hypertension, epilepsy, and high cholesterol, who was severely cognitively impaired and received scheduled pain medication. The care plan indicated the need for analgesic medications as ordered, with monitoring for efficacy and adverse reactions. Despite this, the documentation for Hydromorphone administration was inconsistent, with some doses being signed out by one nurse but not reflected in the MAR, and other doses neither signed out nor documented as administered. Interviews with nursing staff revealed that one nurse began signing for missing doses on the reconciliation log and instructed another nurse to have additional staff sign blank spaces to correct the count. However, the nurse who was asked to sign refused, stating he had not administered those doses and reported the discrepancy to management. The administrator confirmed that the nurse had signed blank spaces on the log and had asked others to do the same, which was acknowledged as improper documentation. Facility policy required immediate documentation of medication administration and shift-to-shift controlled substance counts, but these procedures were not followed in this instance.