Inaccurate Documentation of Controlled Medication Destruction
Penalty
Summary
A deficiency occurred when the facility failed to maintain an accurate record of medication disposition for lorazepam tablets designated for destruction. During a random audit, the Interim Director of Nursing (IDON) and the Administrator (ADM) observed that a bottle of lorazepam 0.5 mg tablets contained 24.5 tablets, while the record sheet indicated only 14.5 tablets were to be destroyed. The IDON acknowledged that the correct number should have been recorded as 24 tablets and confirmed that the count was performed with a Licensed Vocational Nurse (LVN) prior to documentation. LVN B also verified the count of 24.5 tablets and stated she participated in the count with the IDON before documentation. Review of the facility's policy confirmed that the medication disposition record should include the quantity destroyed.