Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to maintain accurate medication records and properly reconcile controlled substances for two residents who were prescribed narcotic pain medications. For one resident with chronic pain, discrepancies were found between the number of Oxycodone pills documented on the proof of use sheet and the actual count in the medication card. The medication administration record (MAR) indicated that more doses were administered than were recorded on the proof of use sheet. Additionally, there were instances where agency nurses documented administration on the MAR but did not sign the proof of use sheet, leading to inconsistencies in the controlled substance count. Another resident, also with chronic pain, experienced similar documentation issues. During medication administration, the nurse prepared and administered Oxycodone without reconciling the medication card with the proof of use sheet. The MAR showed that more doses were given than were recorded on the proof of use sheet. Furthermore, the nurse did not discuss the resident's pain level or inform the resident about the medications being administered. There were also missing or incomplete narcotic shift-to-shift counts, with agency nurses failing to properly sign the count sheets or record their names. Interviews with staff revealed a lack of awareness regarding proper documentation procedures and incomplete education for agency nurses on narcotic handling. Residents reported inconsistencies in receiving their pain medications and a lack of communication from nursing staff about the medications being administered. These failures resulted in inaccurate accounting of controlled substances and incomplete medication records for the residents involved.