Failure to Ensure Proper Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of controlled substances and medication administration according to physician orders. Surveyors observed that narcotic record books on multiple medication carts were missing required signatures from both incoming and outgoing nurses at shift changes. Several nurses confirmed that although narcotics were counted together, signatures were often omitted due to oversight or busy shifts. The Director of Nursing (DON) confirmed that both nurses are expected to sign the narcotic record book after each count, but this was not consistently done. A review of complaints and resident records revealed discrepancies in the documentation and administration of controlled substances. In one case, a resident's controlled drug administration record showed that oxycodone was removed from the narcotic supply on several occasions, but the Medication Administration Record (MAR) did not reflect that the medication was administered, despite the resident being cognitively intact at the time. Another complaint involved a resident who reported increased pain due to missed pain medication, and record review showed that pain medications were administered outside of the physician-ordered pain scale parameters, including both under- and over-medication, as well as administration when not clinically indicated. Further review of another resident's MAR showed that multiple medications, including antihypertensives and pain medications, were administered outside of the physician-ordered parameters, such as giving medications when blood pressure was below the specified threshold or administering pain medication for pain scores lower than required. Additionally, non-pharmacological interventions ordered to be offered prior to PRN medication administration were not documented as provided. These findings were confirmed through interviews with the DON and review of clinical records.