Failure to Document Controlled Medication Administration per Professional Practice
Penalty
Summary
The facility failed to ensure that controlled medications were administered and documented according to professional practice for one medication cart, affecting six residents. During an observation of the medication cart, discrepancies were found between the number of controlled medication tablets or capsules recorded on the Control Substance Record and the actual number present in the medication drawer. In each case, a registered nurse stated that the medication had been administered to the resident and documented as given in the electronic Medication Administration Record, but the removal of the medication was not documented on the Control Substance Record at the time of administration. The residents involved had complex medical histories, including conditions such as Parkinson's disease, chronic obstructive pulmonary disease (COPD), chronic pain, diabetes, hypertension, and other chronic illnesses. All residents were assessed as cognitively intact or nearly intact based on their most recent Brief Interview for Mental Status (BIMS) scores. The controlled medications involved included hydrocodone-APAP, pregabalin, tramadol, and oxycodone, which were prescribed for pain management and other chronic conditions. Interviews with the registered nurse and the Director of Nursing confirmed that the professional practice in the facility required controlled medications to be removed from the drawer, documented on the Control Substance Record, and the final count recorded before administration to the resident. After administration, the medication was to be documented as given in the electronic medical record. Both staff members acknowledged that this process was not followed for the residents in question, but could not provide an explanation for the deviation from established practice.