Failure to Accurately Record and Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly recorded, stored, and reconciled for a resident with multiple diagnoses, including hypothyroidism, diabetes, anxiety disorder, chronic pain, heart failure, and dementia. The resident had moderate cognitive impairment and was care planned for anxiety, with interventions including administration of anti-anxiety medications as ordered. Documentation showed that controlled medications, specifically Lorazepam and Morphine, were delivered and signed for by an LPN, but there was no physician order for Lorazepam prior to a certain date, despite it being added to the shift count earlier. The medication administration record (MAR) for Lorazepam was also missing. Interviews with staff revealed that the medication delivery occurred during a shift change, and the count verification was completed with the incoming nurse. The LPN who signed for the medications later worked on a different hall and was unaware of when the Lorazepam went missing. It was noted that both nurses and medication aides had access to the medication carts, and approximately 10-15 staff members had access to the cart since the medication was received. Facility policy required that only nurses accept medications and that controlled substances be counted at the end of every shift, but this process was not consistently followed. A review of the controlled substance inventory count sheets revealed multiple deficiencies, including missing second signatures, blank spaces, numbers written over other numbers, and missing pages. There were several instances where both on-coming and off-going staff did not sign the count sheets, and gaps in documentation were observed. The DON confirmed that staff were not consistently filling out the forms as required and that a page was missing and could not be found. The facility's policy required detailed record-keeping and reconciliation of controlled substances, but these procedures were not adhered to, resulting in incomplete and inaccurate records.