Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate administration of medications and proper reconciliation and documentation of controlled substances. During a medication administration observation, a registered nurse did not administer the complete dose of a resident's docusate sodium, as significant residue was left in the medication cup after administration. The nurse acknowledged that if residue is observed, more applesauce should be added to ensure the full dose is given, which was not done in this instance. The Director of Nursing confirmed that all medications should be administered as ordered and that the complete dose should be given if residue remains. Additionally, the facility did not accurately reconcile and document controlled medications for a resident. Review of records showed discrepancies between the removal of controlled substances, such as alprazolam and morphine sulfate, and their documentation on the Medication Administration Record (MAR). For example, doses of morphine sulfate were removed at two different times, but only one administration was documented on the MAR. The Director of Nursing verified these discrepancies and acknowledged that the documentation did not match the removal records, indicating a failure in the facility's process for tracking and documenting controlled substances.