Deficient Controlled Substance Documentation and Unlicensed Medication Administration
Penalty
Summary
The facility failed to ensure that pharmaceutical services, specifically the management of controlled medications, were complete and accurate for multiple residents. Discrepancies were found between Controlled Drug Records (CDR) and Medication Administration Records (MAR) for several residents, including instances where medication removals did not correspond to documented administrations. In some cases, documentation was missing or illegible, and shipping manifests, CDRs, and destruction logs were incomplete or could not be located. These documentation failures were observed for at least six residents, with specific examples showing that doses of controlled substances were unaccounted for or not properly reconciled. One significant event involved an unlicensed individual who was employed as nursing staff and used another person's RN license to administer medications. This individual had a revoked LVN license due to prior drug diversion and was found to have signed out controlled substances under another nurse's initials. The facility's records showed that this unlicensed staff member was responsible for discrepancies in the administration and documentation of narcotics, including the removal of medication after a resident had already been transferred to the hospital. The facility's own policies required that only authorized, licensed personnel handle and document controlled substances, and that all removals and administrations be accurately recorded. Further review of the facility's medication management system revealed that for several residents, the required documentation for controlled substances was missing or incomplete. For example, one resident's shipping manifest indicated receipt of a controlled medication, but the corresponding CDR could not be found, and the MAR showed only a few doses administered with the remainder unaccounted for. In other cases, the CDR documented medication removals that did not match any MAR entries, and destruction or return records were not available. These failures were confirmed through interviews with facility staff, who acknowledged the discrepancies and the inability to account for all controlled substances as required by facility policy.