Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain accurate controlled substance records, documentation, and reconciliation in accordance with its own policies and procedures for two of three sampled residents. Licensed nurses did not accurately document or account for controlled substances on the Controlled Drug Records and Medication Administration Records (MAR), resulting in discrepancies between medication removals and documentation. Specifically, for one resident with a history of muscle weakness, liver failure, diabetes, and recent spinal surgery, multiple removals of oxycodone were recorded on the Controlled Drug Record but not reflected on the MAR, with no documentation of refusal, wastage, or return. For another resident with multiple fractures, chronic pain, and osteoporosis, hydrocodone removals were similarly not documented on the MAR, and there was no record of refusal, wastage, or return. Interviews with nursing and pharmacy staff revealed that the facility's process required licensed nurses to verify controlled substances upon delivery, document receipt, and update inventory logs. Each shift change required two nurses to count and reconcile controlled substances, and any discrepancies were to be resolved before the end of the shift or reported to the DON and Administrator. However, review of the Shift Change Controlled Substance Inventory Log showed multiple calculation inaccuracies, with incorrect counts recorded on several dates. The DON acknowledged that required audits were not performed as stipulated by facility policy. The facility's policy mandated that all controlled substances be accounted for and that documentation on the Controlled Drug Record must match the MAR. The policy also required that any discrepancies be resolved or reported immediately, and that staff not leave until discrepancies were addressed. Despite these requirements, the facility did not ensure accurate documentation or reconciliation of controlled substances, leading to delayed detection of potential diversion and placing residents at risk for medication errors.