Incomplete and Inaccurate Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete regarding the administration of controlled substances for two residents. For one resident with multiple diagnoses including diabetes, COPD, and chronic kidney disease, there was a discrepancy between the Individual Patient Controlled Substance Administration Record and the Medication Administration Record (MAR) for Hydrocodone-Acetaminophen. The controlled drug record indicated the medication was administered at a specific time, but the MAR did not reflect this administration. This discrepancy was confirmed during an observation of the medication cart and through interviews with facility staff. For another resident with a history of hemiplegia, diabetes, and chronic pain, the MAR showed that Oxycodone was administered at bedtime, but the narcotic count sheet marked this dose as an error, suggesting it was not given. Additionally, two narcotic sheets for this resident lacked critical information such as the date and amount of narcotic received, amount sent, and the signature of the person receiving the medication. These omissions were verified by staff interviews and were not in accordance with the facility's policy for controlled medication storage and accountability.