Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled medications for three residents who were prescribed hydrocodone-acetaminophen for pain management following orthopedic and spinal injuries. For one resident, the Controlled Drug Record (CDR) indicated a dose was administered, but this was not reflected in the Medication Administration Record (MAR). For another resident, multiple instances were found where the CDR showed administration of the medication, but the MAR did not document these doses. In a third case, there was a discrepancy between the administration times recorded in the CDR and the MAR for the same dose. Interviews with the Director of Nursing confirmed the importance of correct documentation for controlled drug accountability and acknowledged that incorrect records could be associated with medication misuse and drug diversion. The facility's policy required immediate and accurate documentation of controlled medication administration on both the accountability record and the MAR, including date, time, amount administered, and the nurse's signature, but this procedure was not consistently followed.