Failure to Accurately Document and Report Administration and Wastage of Controlled Substances
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident who was prescribed Oxycodone/Acetaminophen 10/325MG, resulting in multiple documentation and reporting errors by nursing staff. Specifically, one nurse did not document the administration of the medication on the Medication Administration Record (MAR) after giving it to the resident. Additionally, two other nurses failed to record the administration of the same medication on the Narcotic Record Count Sheet after giving it to the resident. These lapses led to inconsistencies between the MAR and the narcotic count sheet, making it unclear how many doses were actually administered and how many pills should have remained in inventory. Further compounding the issue, one nurse failed to notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) about a discrepancy involving two missing pills, as required by facility policy. Instead, the nurse documented the pills as wasted on the narcotic count sheet and had another nurse sign as a witness, even though the witnessing nurse did not actually observe the medication being wasted. This was contrary to facility policy, which requires two nurses to witness and sign off on the destruction of controlled substances. Interviews with staff revealed confusion and lack of adherence to proper procedures for documenting, counting, and reporting discrepancies with controlled medications. The resident involved was an older female admitted with a fractured patella, muscle weakness, and lack of coordination, and had an order for Oxycodone/Acetaminophen as needed for pain. Documentation reviews and staff interviews confirmed that the required records for administration and wastage of the medication were incomplete or inaccurate, and that staff did not consistently follow the facility’s policies for handling controlled substances. The discrepancies in documentation and failure to report missing medication were directly observed and verified by facility administration during the investigation.