Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances in accordance with professional standards of practice and its own policy. Licensed nurses were required to count all controlled medications at every change of shift, with reconciliation performed jointly by outgoing and incoming nurses, and documentation required at the time of administration. However, observations and record reviews revealed that an LPN did not accurately complete and reconcile controlled medication record sheets for four sampled residents. The LPN administered controlled medications but failed to document the administration on the Individual Patient Controlled Substance Administration Record (IPCSAR) at the time the medications were given. Instead, the LPN completed the documentation later, in front of a surveyor, and recorded the time as after the actual administration. The residents involved had various medical conditions, including cerebral infarction, paranoid schizophrenia, contractures, Parkinson's disease, osteoarthritis, anxiety disorder, chronic pain, COPD, and dementia. Each resident had physician orders for controlled medications such as gabapentin, pregabalin, morphine sulfate, oxycodone, and lorazepam. Medication Administration Reports (MARs) indicated that the medications were given as scheduled, but the corresponding controlled substance records were not signed at the time of administration. In some cases, the LPN provided explanations for the lack of timely documentation, such as not having a pen, and stated an intention to complete the records after finishing medication administration. Interviews with other nursing staff and the Director of Nursing confirmed that the facility's policy required controlled medications to be signed out at the time of administration and that staff had been educated on this process. The Director of Nursing acknowledged ongoing issues with nursing documentation and stated that all staff, including agency nurses, were expected to follow established procedures for controlled medication counts and documentation. The administrator also confirmed the expectation that nurses follow all facility policies for controlled substances, including logging and documentation at the time medications are given.