Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medication administration for a resident, specifically regarding hydrocodone/APAP 5-325 mg tablets. According to facility policy, when a controlled medication is administered, the licensed nurse must record the date, time, and amount administered on the accountability record, and all medications given must be documented on the Medication Administration Record (MAR). For one resident, the Tab Narcotic and Hypnotic Record showed that on one occasion, one tablet was removed from the supply, but the MAR indicated that two tablets were administered for a pain level of 7. The Director of Nursing (DON) confirmed that the nurse had accidentally signed for two tablets instead of one. On another occasion, the Tab Narcotic and Hypnotic Record showed that one tablet was removed from the supply, but there was no documentation on the MAR to indicate whether the medication was administered. The DON verified that the administration of the controlled medication was not documented as required. These discrepancies were identified through interviews, medical record reviews, and facility document reviews, and were confirmed by the DON during concurrent record review.