Failure to Ensure Accurate Documentation and Oversight of Controlled Substance Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents by not ensuring accurate dispensing and administration of controlled substances, specifically oxycodone, for two out of three residents reviewed. For one resident with diagnoses including bipolar disorder and multiple fractures, the narcotic control sheets indicated that oxycodone was signed out numerous times over several months, but there was no corresponding documentation in the Medication Administration Record (MAR) for a significant number of those instances. The resident reported not receiving pain medication as ordered, particularly during overnight shifts, and expressed concerns about possible drug diversion, which they stated were not taken seriously by staff. Interviews with nursing staff confirmed that pain medications administered were not always documented in the MAR, citing being busy as a reason for incomplete records. For another resident admitted with a femur fracture and pain, the narcotic control sheets also showed oxycodone was signed out multiple times, but half of those administrations were not documented in the MAR. This resident, however, reported receiving pain medication consistently and denied any issues with administration. Observations confirmed that narcotics were physically accounted for, and security protocols for medication storage were followed. Despite this, staff interviews revealed a pattern of incomplete documentation, with some nurses relying on narcotic control sheets rather than the MAR to track administration times. The facility's policy required staff to document medication administration in the MAR immediately after giving each dose, but this was not consistently followed. The pharmacy consultant, who worked offsite, only reviewed the MAR and did not audit narcotic control sheets or pain assessments, as per the contract with the facility. The Director of Nursing acknowledged that there was no formal process to reconcile narcotic control sheets with the MAR, and the pharmacist did not conduct onsite reviews. This lack of oversight and incomplete documentation led to discrepancies in the administration records of controlled substances.