Failure to Document Controlled Substance Administration and Removal
Penalty
Summary
The facility failed to properly document the removal and wasting of controlled substances on the Controlled Substance Distribution Record (CSDR) for one resident, and failed to record the administration of controlled medications on the Medication Administration Record (MAR) for two residents. Specifically, for one resident with diagnoses including Type 2 Diabetes Mellitus, chronic heart failure, and End Stage Renal Disease, the CSDR did not indicate that Fentanyl patches administered on two occasions were removed or wasted according to facility policy. Additionally, a 100 microgram/hour Fentanyl patch administered to the same resident was not documented as removed or wasted, despite policy requiring two licensed professionals to destroy and document the destruction of controlled substances. For the same resident, the MAR did not reflect the administration of a 100 microgram/hour Fentanyl patch, even though the CSDR showed it was given. Another resident, with a history of diabetes, chronic heart failure, and chronic pain syndrome, was administered Tramadol as documented on the CSDR, but this administration was not recorded on the MAR. Facility policy requires that nurses document the administration of medications on both the MAR and CSDR at the time the medication is given. Interviews with the Interim Director of Nurses confirmed that the facility's policy mandates documentation of both the administration and removal/wasting of controlled substances, with two nurses required to sign off on the removal/wasting. The review of facility policies and records demonstrated that these procedures were not consistently followed for the residents in question.