Failure to Accurately Reconcile Controlled Medication Doses
Penalty
Summary
The facility failed to maintain an accurate system for recording the disposition of controlled drugs for one resident. Specifically, the medication reconciliation log for a Schedule II medication, Norco 5/325, did not accurately reflect the number of doses administered. On review, the Medication Administration Record (MAR) indicated that a morning dose had been given and 16 doses remained, but the controlled medication reconciliation log showed 17 doses available, while only 16 doses were physically present in the blister pack. This discrepancy was confirmed during an interview with the Medication Aide, who acknowledged the importance of immediately documenting the administration of controlled substances to prevent errors in the count. The resident involved was a female with chronic pain syndrome, anxiety disorder, hypertension, recurrent depressive disorders, hyperlipidemia, and pseudobulbar affect. She was moderately cognitively impaired and had been receiving both scheduled and as-needed pain medications. The facility's policies required that all controlled substances be recorded on the designated usage form and that the dose recorded on the usage form must match the MAR and other facility records. However, these procedures were not followed, resulting in an inaccurate reconciliation of the controlled medication.