Failure to Accurately Document Controlled Drug Administration
Penalty
Summary
The facility failed to accurately document the administration of a controlled medication, specifically Percocet, for a resident with multiple complex medical conditions including neuropathy, diabetes, chronic pain, and moderate cognitive impairment. Review of records showed several instances where Percocet was removed for PRN administration as documented on the controlled drug record (CDR), but there was no corresponding documentation on the medication administration record (MAR) to confirm that the medication was actually administered. This discrepancy occurred on multiple dates and times, indicating a pattern of incomplete or missing documentation for controlled substances. The issue came to light following an allegation by the resident that an LPN gave the wrong medication and stole her Percocet. Investigation revealed that the LPN in question was suspended, tested positive for benzodiazepines without a current prescription, and was later terminated. Interviews with staff and review of facility policy confirmed that nurses are required to document all administered controlled medications on both the MAR and CDR to prevent medication errors. The facility's failure to ensure accurate and complete documentation for controlled drug administration created the potential for significant medication errors and/or misappropriation.