Inaccurate Controlled Drug Records and Inadequate Pharmacist Review
Penalty
Summary
The facility failed to ensure the accuracy of controlled drug records for three residents, as evidenced by discrepancies between the Controlled Drug Record (inventory of scheduled drugs) and the Medication Administration Record (MAR). For one resident, the amount of morphine recorded in the Controlled Drug Record did not match the actual amount in the bottle, and the MAR did not show administration of the medication on dates when the Controlled Drug Record indicated doses were removed. For another resident, the Controlled Drug Record showed removal of hydrocodone/APAP tablets on specific dates, but the MAR did not reflect administration of those tablets on the same dates. A third resident's MAR indicated daily administration of hydrocodone/APAP, but the Controlled Drug Record did not show corresponding removals for each day. These discrepancies were identified during concurrent observations, interviews, and record reviews conducted by surveyors with nursing staff, including an LVN and the Director of Nursing (DON). The DON acknowledged that the Controlled Drug Records and MARs did not match and stated that her expectation was for scheduled medication records to be accurate. The inconsistencies were confirmed through direct inspection of medication bottles, review of Controlled Drug Records, and comparison with MARs. Additionally, the facility's Consultant Pharmacist failed to identify these discrepancies during routine reviews. The Consultant Pharmacist's reports for the previous three months did not mention any issues with the accuracy of controlled medication documentation. The facility's policy required the pharmacist to establish a system for accurate reconciliation of controlled drugs, but the observed practice did not meet this standard.