Inaccurate Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medication administration for one resident. During an inspection of a medication cart, two controlled drug count sheets for a resident's buprenorphine patch were found to have inaccurate counts. A licensed nurse administered a buprenorphine patch to the resident but documented the administration on the wrong count sheet, which was associated with a different prescription. This resulted in both count sheets reflecting incorrect medication counts. The error was not detected during the routine inventory count conducted by nurses at shift change. Interviews with nursing staff and the Director of Nursing confirmed the documentation error and the resulting discrepancies in the controlled medication records. The facility's policy requires that two licensed nurses conduct a physical inventory of all controlled medications at each shift change and document the results on the accountability record. Any discrepancies are to be reported immediately to the Director of Nursing. In this instance, the required procedures were not followed, leading to inaccurate recordkeeping for the resident's controlled medication.