Failure to Maintain Accurate Controlled Substance and Medication Administration Records
Penalty
Summary
The facility failed to maintain accurate controlled substance and medication administration records for multiple residents, as well as for two medication carts. Surveyors observed discrepancies between the number of controlled medications recorded in the controlled substance book and the actual count in the medication carts. For example, one cart was documented as containing 45 controlled medications, but only 44 were present. In another instance, a controlled drug record indicated 17 mL of morphine concentrate remained, while the actual amount in the bottle was approximately 23 mL. Staff interviews revealed inconsistent practices in counting and documenting controlled substances, with some nurses reporting that medications were signed out on the controlled drug record but not on the medication administration record (MAR), and vice versa. Review of records for several residents revealed numerous instances where controlled medications were signed out as removed from the medication cart but were not documented as administered on the MAR. In some cases, the times recorded on the controlled drug record and the MAR did not match, and in others, signatures were suspected to be forged. Residents reported not receiving pain medications that were documented as administered, and staff expressed concerns about possible signature forgeries and discrepancies in medication documentation. These issues were noted across multiple residents with various diagnoses, including chronic pain, cancer, sepsis, osteoarthritis, and fractures. Interviews with nursing staff and the DON confirmed awareness of ongoing discrepancies and concerns regarding the administration and documentation of controlled substances. Staff described processes where medications were removed from the cart and documented on the controlled drug record, but not always immediately signed out on the MAR, especially if there was uncertainty about whether the resident would take the medication. Investigations into signature authenticity and medication administration were initiated after staff raised concerns, but discrepancies persisted, as evidenced by the surveyors' findings during their review.