Failure to Document Controlled Drug Administration in Narcotic Log
Penalty
Summary
The facility failed to maintain accurate records of receipt and disposition of controlled drugs for two residents, as required by state and federal regulations. Specifically, a medication aide administered Xanax to a resident with dementia, anxiety disorder, and major depressive disorder, and Tramadol to another resident with multiple fractures and pain, but did not document the administration of these controlled substances in the narcotic log at the time of administration. The medication administration records indicated that the medications were given, but the corresponding narcotic logs were not updated as required. During an inspection, it was observed that the narcotic log for Xanax did not reflect the medication being signed out, and the medication aide attempted to retroactively document the administration of Tramadol. The medication aide acknowledged forgetting to document in the narcotic logs immediately after administration, which was confirmed by the DON as a violation of facility policy and procedure. Facility policy required that all controlled medications be documented on the control sheet immediately after administration, and the failure to do so resulted in an inaccurate narcotic count.