Failure to Accurately Reconcile and Document Controlled Medication Administration
Penalty
Summary
The facility failed to establish and implement a consistent and accurate system for reconciling controlled medications, specifically Lorazepam 0.5mg, for a resident with a history of non-Alzheimer's dementia, hypertension, and senile degeneration of the brain who was on hospice care. The resident had physician orders for Lorazepam to be administered as needed for anxiety or agitation. During a surveyor's observation, the medication blister pack for Lorazepam was found to have two broken seals: one with the pill still inside and taped over, and another with the pill missing. The documented count was 12 pills, but only 11 were present in the blister pack. Interviews with nursing staff revealed that the nurse responsible for administering the medication did not notice the missing pill or the broken blister seals until it was brought to her attention by the surveyor. The nurse admitted to making a documentation error, initially recording that two pills were given instead of one, and later making a late entry to correct the mistake. The nurse also failed to sign the narcotic count sheet at the time of administration. The DON confirmed that facility policy requires any broken blister pack seal to result in the pill being discarded by two nurses, and that taping over a broken seal is not acceptable. However, this protocol was not followed in this instance. Further interviews with other nursing staff indicated that narcotic counts were performed at shift changes, but the broken blister and missing pill were not detected during these counts. The facility's policy on controlled substances outlines detailed procedures for handling, documenting, and reconciling controlled medications, but these procedures were not consistently followed, resulting in an inaccurate account of the controlled drug and a failure to maintain proper records of receipt and disposition.