Failure to Ensure Timely Medication Administration and Proper Controlled Substance Documentation
Penalty
Summary
The facility failed to provide routine medications to residents in a timely manner and did not ensure that controlled drug records were properly maintained and signed out by administering staff. During an observation of medication carts, a nurse was seen removing multiple narcotic cards from the narcotic medication drawer, where a loose tablet was also found. The medication count sheet for these narcotics was blank, yet the nurse admitted to signing it out at the instruction of another nurse. Additionally, a resident reported not receiving her prescribed pain medication over a weekend and experiencing a significant delay in receiving her pain pill in the morning. Review of her medication administration record confirmed that she only received Tylenol for pain during the period in question, despite having orders for other pain medications. Further investigation revealed discrepancies in the documentation and administration of controlled substances. The Director of Nursing (DON) acknowledged that a medication prescription label on a narcotic card had been altered, with the original dosage crossed out and a new dosage handwritten above. The DON described a process for removing controlled substances from medication carts after resident discharge, but was unable to account for a large number of medication cards belonging to discharged residents still present on the carts. Interviews with nursing staff revealed that nurses were signing out narcotics for each other, contrary to facility policy and regulations, and that signatures on narcotic count sheets did not always correspond to the nurse who administered the medication. Staff interviews and documentation review indicated a lack of adherence to established protocols for controlled substance handling, including proper documentation and timely removal of discontinued or discharged medications. Despite these issues, pharmacy consultant reports from the previous three months did not identify any problems with medication carts or controlled substance logs during their inspections.