Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to ensure that the Medication Administration Record (MAR) and the Individual Count Sheet Record for controlled substances coincided as required by facility policy for one resident. Specifically, a resident with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and who was receiving palliative care, was readmitted and had a physician's order for lorazepam oral concentrate to be administered as needed for anxiety. On a specified date, the MAR indicated that lorazepam was administered to the resident, but there was no corresponding documentation on the Individual Count Sheet Record to confirm this administration. During an interview and record review, the DON confirmed that the MAR showed lorazepam was given, but the Individual Count Sheet Record did not reflect this, which was inconsistent with facility policy. The policy required that when a controlled medication is administered, the licensed nurse must immediately document the administration on both the accountability record and the MAR, including the date, time, amount, and nurse's signature or initials. The failure to document on both records as required was observed and acknowledged by the DON.