Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to accurately document and reconcile controlled substances for two residents, resulting in incomplete and inconsistent records in the Controlled Substance Record Book. For one resident with a diagnosis of malnutrition and an order for dronabinol, a controlled substance, staff did not document medication administration for two consecutive days and failed to count the medication at shift changes because it was stored in a medication refrigerator rather than the medication cart. The Medication Administration Record indicated the medication was administered as ordered, but the inventory page showed missing and inconsistent entries, with staff later entering documentation for the missed days after being questioned. For another resident with an order for oxycodone as needed for pain, the facility's incident report revealed that documentation in the Controlled Substance Record Book was missing administration times and included entries for days when the resident was not present in the facility. The Director of Nursing confirmed that staff had not followed procedures for documenting and reconciling controlled substances, and multiple documentation errors were identified, including failure to review all pages of the record book and to ensure accurate medication counts during shift changes.