Failure to Accurately Account for and Document Controlled Drug
Penalty
Summary
The facility failed to ensure accurate accounting and documentation of a controlled drug, Lyrica, for one resident. The resident, who had diagnoses including hypertension, seizure disorder, and hemiplegia, was admitted with the capacity to make decisions and required moderate assistance with daily activities. Upon review, discrepancies were found in the documentation and physical count of Lyrica pills. The Controlled Medication Destruction Log indicated that 28 pills were turned in for destruction, but there was no signature to confirm receipt. The Director of Nursing (DON) did not sign the form due to an incorrect drug count, and the medication bubble pack showed 28 pills remaining, while the controlled drug record form indicated 30 pills. The DON stated that the nurse administered doses without documenting them and that proper handoff and drug count procedures during shift changes were not followed. Further review and interviews confirmed that the documentation did not accurately reflect the location or disposition of the controlled drug, and the process for destruction and reconciliation was incomplete. Facility policies required that controlled substances be reconciled at various points, including administration and shift changes, and that both the administering nurse and a witness sign off on the destruction of medications. The Licensed Vocational Nurse job description also required timely and accurate documentation of medication administration, which was not adhered to in this instance.