Failure to Administer Controlled Medications per Physician Orders and Document Properly
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents. For one resident with polyneuropathy and low back pain, the physician's order specified hydrocodone-acetaminophen 5-325 mg to be given every six hours as needed for pain. However, review of the controlled drug record showed that doses were administered at intervals shorter than six hours on multiple occasions, and some doses were not documented on the Medication Administration Record (MAR) as required. The resident was cognitively intact and reported taking the medication as needed for pain. For another resident with acute respiratory failure, COPD, and diabetes with neuropathy, the physician's order was for oxycodone HCl 5 mg by mouth every six hours as needed for pain. Documentation revealed that doses were signed out at intervals less than six hours apart on several dates, and there were discrepancies between the MAR and the controlled drug record, including illegible times and missing documentation. Interviews with nursing staff and the Director of Nursing confirmed that controlled medications were not consistently documented in both the MAR and the proof of use sheets, and that some doses were administered too close together, contrary to physician orders.