Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure that drug records were accurately maintained and that an account of all controlled drugs was kept for multiple residents. During an inspection of a medication cart, discrepancies were found between the number of controlled medication pills documented on individual medication records and the actual number of pills present in the blister packs for eight residents. These discrepancies were observed for various controlled substances, including phenytoin, acetaminophen-codeine, clonazepam, pregabalin, alprazolam, tramadol, and lorazepam. The medication aide responsible for administering these medications did not document the administration of controlled substances on the individual controlled medication records immediately after giving the medication. Instead, the aide reported typically signing out the controlled medication sheets during the shift count with oncoming staff, rather than at the time of administration. This practice resulted in mismatches between the recorded and actual pill counts for several residents with diagnoses such as epilepsy, chronic pain syndrome, anxiety disorder, fibromyalgia, and joint pain. Interviews with facility leadership, including the DON and the Administrator, confirmed that the expectation was for staff to sign out controlled medications immediately after administration, as outlined in the facility's policy. The policy requires that controlled substance inventory sheets be accurately maintained and that a log is used to track controlled substances from delivery to disposition, in accordance with federal and state regulations. The failure to follow these procedures led to the observed discrepancies in medication records.