Failure to Safeguard and Accurately Document Controlled Medications
Penalty
Summary
The facility failed to ensure that medication records were properly completed and safeguarded, resulting in incomplete medical records that do not meet accepted professional standards. A resident with multiple diagnoses, including hypothyroidism, type 2 diabetes mellitus, anxiety disorder, chronic pain, heart failure, and dementia, was admitted and had a care plan addressing anxiety with interventions for anti-anxiety medication administration. However, there was no physician order for Lorazepam prior to a certain date, despite the medication being added to the shift count and signed for by an LPN. The medication administration record (MAR) sheet for Lorazepam was missing, and the facility was unable to account for when the medication went 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 responsible for accepting the medication stated that documentation was completed and a MAR sheet was created, but could not specify when the Lorazepam went missing due to being assigned to a different hall. The DON confirmed that multiple staff members, including 10-15 nurses and medication aides, had access to the medication cart, and that policy required staff to count controlled substances at the end of every shift. However, review of the controlled substance inventory count sheets showed numerous deficiencies, including missing signatures, blank spaces, numbers written over each other, and gaps in documentation. Facility documentation and policy review further revealed that the process for medication orders from hospice involved faxing orders to the nursing station, with the responsible nurse documenting the medications. Despite this, the required documentation for Lorazepam was not present, and the controlled substance sheets were not consistently or accurately completed. The facility's abuse and neglect policy emphasized the need to prevent misappropriation of resident property, but the lack of accurate recordkeeping and control over medication access led to the deficiency.