Failure to Reconcile Controlled Drug Administration Records
Penalty
Summary
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and maintaining accurate records of their administration for two residents. According to the facility's Medication Administration policy, medications are to be prepared and administered only by authorized personnel, with each administration documented immediately on the medication administration record (MAR). However, a review of controlled substance records and MARs for two residents revealed discrepancies: doses of Ativan, a controlled antianxiety medication, were signed out on the controlled substance records as removed for administration, but these doses were not documented as administered on the corresponding MARs. One resident, with diagnoses including dementia, anxiety, and mood disorder, had multiple doses of Ativan signed out on the controlled substance record over several dates, but these administrations were not reflected on the MAR. The resident was noted to be severely cognitively impaired and required assistance with activities of daily living. Similarly, another resident with dementia and anxiety had numerous doses of Ativan signed out on the controlled substance record across several months, but these were also not documented on the MAR as administered. During an interview, the Director of Nursing confirmed the inconsistencies between the controlled drug records and the MARs, acknowledging that doses were documented as given on the narcotic reconciliation record but not signed out as administered on the MAR. These findings indicate a failure to follow established pharmacy and medication administration procedures as required by facility policy and state regulations.