Failure to Rotate Injection Sites and Incomplete Controlled Substance Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not rotating injection sites for enoxaparin, an anticoagulant medication, as required by facility policy. Documentation showed that the medication was repeatedly administered to the same area of the resident's upper arms over several days, rather than rotating sites as directed. This resulted in the resident developing bluish to greenish discoloration on the right upper arm, which was observed during an interview and not previously assessed, monitored, or reported to the physician or family representative as required. Additionally, the facility did not ensure accurate reconciliation and documentation of a controlled substance, oxycodone HCl IR, for the same resident. The medication was documented as administered on the Controlled Drug Record but was not recorded on the electronic Medication Administration Record (MAR). Staff interviews confirmed that the medication was removed from the bubble pack and given to the resident, but the administration was not properly documented in the MAR immediately after, as required by facility policy. The resident involved had no capacity to exercise rights or sign necessary documents and was receiving enoxaparin for DVT prophylaxis and oxycodone for pain management. Facility staff, including LVN, RN, and DON, verified the findings during interviews and record reviews, confirming that both the failure to rotate injection sites and the failure to accurately document controlled medication administration occurred.