Failure to Accurately Administer and Document Controlled Medications
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and did not ensure accurate documentation of controlled substances in the Medication Administration Record (MAR) for two residents. For one resident with a history of seizures, dementia, COPD, and bipolar disorder, the MAR indicated that Clonazepam was administered on two occasions. However, a review of the resident's bubble pack and Narcotic and Hypnotic Record showed that the medication was not actually given, as the count of tablets remained unchanged and there was no documentation of administration in the controlled substance log. The nurse had signed the MAR as if the medication was given, but the physical count and records did not support this. Similarly, for another resident with depression, anxiety disorder, and schizophrenia, the MAR showed that Lorazepam was administered, but the bubble pack and Narcotic and Hypnotic Record indicated that the medication was not dispensed, as the tablet count was unchanged and there was no documentation in the controlled substance log. The nurse had again signed the MAR as if the medication was given, but the actual count and records did not match. Both discrepancies were identified during a concurrent review and interview with facility staff, who confirmed that the medications should not have been charted as given if they were not administered. Facility policy requires that controlled medications be documented accurately in both the MAR and the Narcotic and Hypnotic Record, in accordance with federal and state regulations. The Director of Nursing and Assistant Director of Nursing were not aware of the discrepancies until the review, and acknowledged the importance of regular audits to ensure medications are administered and documented correctly. The failure to accurately document and administer controlled medications was confirmed through interviews, record reviews, and medication counts.