Failure to Accurately Document and Administer Controlled Substances
Penalty
Summary
The facility failed to safely administer and accurately document controlled substances for residents identified as receiving these medications. During a medication pass, it was observed that narcotic sheets on a medication cart were not accurately completed, and discrepancies in the shift-to-shift narcotic count records were noted. Documentation errors included incorrect counts, overwriting of numbers, missing signatures from incoming nurses, and incorrect dates on narcotic count forms. Interviews with LPNs confirmed that not all nurses were following the same procedures for counting and documenting controlled substances, making the records difficult to follow and leading to inconsistencies. Further review by the Director of Nursing revealed blank spots on narcotic sheets and missing signatures for the administration of controlled substances such as Tramadol and Ativan for a resident. The physical count of medications did not match the documentation, indicating further errors. The facility's policy required a physical inventory of all controlled substances by two licensed nurses each shift, with immediate reporting of discrepancies, but these procedures were not consistently followed, resulting in inaccurate recordkeeping and potential mismanagement of controlled substances for multiple residents.