Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to maintain an established system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. Specifically, there were multiple instances where documentation of controlled substances, including Morphine and ABH cream, was missing from the Medication Administration Record (MAR) and the Controlled Drug Receipt/Disposition Forms for a resident with significant cognitive impairment and multiple comorbidities. The discrepancies included missing entries for both the administration and disposition of these medications across several dates in April and May. The resident involved was an elderly female with diagnoses including dementia, Alzheimer's disease, generalized anxiety disorder, and was receiving palliative care. She required substantial assistance with activities of daily living and was on several psychotropic and pain medications, including controlled substances. Physician orders for Morphine and ABH cream were present, but the MARs and controlled drug logs did not consistently reflect administration as ordered. For example, there were documented administrations on the MAR that were not recorded on the controlled drug logs, and vice versa, as well as missing documentation altogether for certain dates and times. Interviews with nursing staff revealed that medications were likely administered but not documented due to forgetfulness or the challenging behavior of the resident. Staff admitted to omitting documentation on both the MAR and controlled drug logs, and there was no established procedure in place at the time to routinely reconcile these records. The facility's own policies required accurate and timely documentation of controlled substances, but these were not followed, resulting in incomplete records and the inability to accurately account for all controlled drugs administered to the resident.