Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete regarding the administration of controlled substances for multiple residents. Surveyors identified discrepancies between the Controlled Drug Record and the Medication Administration Record (MAR) for five residents who were prescribed and administered various controlled medications, including Hydrocodone-Acetaminophen, Tramadol HCL, Ativan, and Oxycodone-Acetaminophen. In each case, the Controlled Drug Record indicated that the medication had been administered at specific times, but the corresponding MAR entries were either missing or incomplete for those administrations. For example, one resident with diagnoses including hemiplegia, dementia, and heart failure had orders for Hydrocodone-Acetaminophen, which was documented as administered in the Controlled Drug Record but not reflected in the MAR for two doses. Another resident with multiple sclerosis, hypertension, and chronic kidney disease received Tramadol HCL and Ativan according to the Controlled Drug Record, but the MAR lacked documentation for these administrations on several dates. Additional residents with complex medical histories, such as chronic obstructive pulmonary disease, diabetes, and chronic pain, also had similar discrepancies between the Controlled Drug Record and the MAR for their prescribed controlled substances. During an interview, the Director of Nursing confirmed the discrepancies and acknowledged that all administered medications should be documented in the medical records at the time of administration, as required by the facility's medication administration policy. The facility's policy specifically states that after administration, documentation must occur in both the MAR and the controlled substance sign-out record. The failure to maintain accurate and complete records for controlled substance administration was observed for multiple residents during the survey.