Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate reconciliation and documentation of controlled medications for multiple residents. Specifically, a medication aide (MA B) did not accurately document the administration of several controlled substances, including tramadol, acetaminophen-codeine, oxycodone, lorazepam, methylphenidate, hydrocodone-acetaminophen, and clonazepam, on the narcotic medication logs for four residents. These discrepancies were identified during medication cart reconciliation and interviews, where MA B admitted to administering the medications but failing to record them due to being busy throughout the day. The affected residents had complex medical histories, including acute pain, stroke, intellectual disabilities, heart failure, chronic pain, schizoaffective disorder, bipolar disorder, dementia, and anxiety. Their care plans required timely and accurate administration and documentation of pain and psychotropic medications. Record reviews showed that the medication administration records indicated the medications were given, but the narcotic logs did not match the actual counts in the medication cards, revealing missing documentation for doses administered by MA B. Interviews with the DON, other nursing staff, and residents confirmed that the residents received their medications as prescribed, and no staff reported suspicious behavior or prior narcotic discrepancies. The DON and staff attributed the discrepancies to documentation errors rather than diversion, and a misplaced pill was found and destroyed. The facility's policy required detailed documentation of controlled substance administration, which was not followed in these instances, resulting in inaccurate narcotic logs for the residents involved.