Failure to Administer and Document Controlled Substances per Professional Standards
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for six of eight residents reviewed, specifically regarding the administration and documentation of controlled substances. Facility policy required medications to be administered safely, timely, and as prescribed, with proper documentation on the Medication Administration Record (MAR) and controlled substance records. However, multiple discrepancies were identified, including missed doses, administration of incorrect medications, and inaccurate or missing documentation. For example, one resident with chronic pain and osteoarthritis did not receive a scheduled dose of oxycodone and was instead given loratadine, an over-the-counter allergy medication, which was confirmed by pill identification and resident report. The MAR and controlled substance records showed signatures for medication administration at times when the responsible nurse was not present in the facility, and the nurse's own statement did not address the missed dose. Other residents with diagnoses such as COPD, diabetes, anxiety, and depression also experienced inconsistencies in the administration and documentation of their prescribed oxycodone. In several cases, the controlled substance records indicated that medication was dispensed and signed out by an LPN at times when she was not on duty, or the MAR did not reflect that the medication was given. Some residents reported not receiving pain medication despite records indicating otherwise, and in some instances, documentation was completed before or long after the medication was reportedly administered. Interviews with residents corroborated these discrepancies, with several stating they did not receive medication as documented or only took medication at specific times contrary to the records. The facility's own leadership acknowledged that controlled substances should be documented immediately after administration, not an hour or more later, and that every administration should be recorded. The investigation revealed a pattern of improper medication handling, including failure to follow policy for controlled substances, inaccurate recordkeeping, and administration errors. These failures were substantiated through policy review, clinical record review, facility investigation, and interviews with residents and staff.