Failure to Accurately Record Controlled Drug Administration
Penalty
Fine: $79,870
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
Facility staff failed to maintain accurate records of controlled drugs for two of thirty sampled residents during a medication pass and pour observation. On two separate occasions, LPNs prepared and administered controlled medications—Oxycodone 5/325 mg for one resident and Gabapentin 100 mg for another—without signing the medications out in the narcotics book at the time of preparation or after administration. These actions were directly observed by the surveyor, and the facility's policy on controlled substance medication orders was reviewed, which indicated that applicable protocols are to be followed closely. No additional information was provided to the survey team prior to exit.