Failure to Document Controlled Substance Administration in Medication Records
Penalty
Summary
The facility failed to implement its pharmaceutical procedures for controlled substances when nursing staff did not ensure accurate accountability for a resident's medication. Specifically, hydrocodone-acetaminophen tablets were signed out of the Controlled Drug Record (CDR) for a resident on multiple occasions, but there was no corresponding documentation of administration on the Medication Administration Record (MAR) for those dates and times. The facility's policy requires that controlled medications be documented both in the CDR and the MAR, but this process was not followed. Interviews with nursing staff and the Director of Nursing confirmed that the expected procedure is to document the administration of controlled medications in both the CDR and the MAR. Review of the resident's records verified that the medication was signed out in the CDR but not recorded as administered in the MAR, despite an active order for the medication during the relevant period. The discrepancy was acknowledged by staff during interviews and concurrent record reviews.