Failure to Accurately Document and Account for Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services and maintain accurate medication records for a resident with multiple diagnoses, including a femur fracture and dementia, who was prescribed oxycodone for pain management. Review of medication administration records and controlled drug logs revealed that licensed staff signed out controlled pain medication from the control book but did not consistently document administration on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). Specifically, on multiple occasions, staff signed out oxycodone but failed to sign off on the MAR or TAR, creating discrepancies in medication tracking. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and involved staff confirmed that the required documentation was missing. The DON and ADON stated that if medication was not signed off on the MAR or TAR, it indicated the medication was not administered, constituting a medication error. Additionally, there was confusion and lack of proper procedure regarding the destruction of unused controlled medications, as staff could not recall or provide evidence of proper witnessing and documentation of medication wastage as required by facility policy. Facility policy mandates that all administered medications must be documented on the MAR or TAR and that wastage of controlled substances must be witnessed by two licensed nurses and recorded accordingly. The failure to follow these procedures resulted in incomplete records, potential medication errors, and lack of accountability for controlled substances, as evidenced by the discrepancies between the control book and the MAR/TAR, and the absence of proper documentation for medication destruction.