Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications in its emergency narcotic E-box and for two residents. According to facility policy, nurses are required to fully document the removal of emergency medications, including completing and faxing a sign-out sheet to the pharmacy, logging entries with signatures, and reconciling medication counts with controlled substance records. However, for one resident receiving hospice care for ovarian cancer, there was no documentation on the controlled substance record for two doses of Ativan solution that were administered, and the medication was later found missing from the E-box. The missing Ativan was not reported to the Director of Nursing, management, or pharmacy as required, and staff did not follow proper procedures for counting and documenting medications when accessing the E-box, making it impossible to determine when the medication went missing. For another resident with a diagnosis of atrial fibrillation, controlled substance records indicated that multiple doses of Tramadol were signed out on various dates. However, there was no documented evidence on the Medication Administration Record (MAR) that these doses were actually administered to the resident. This discrepancy was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation for the signed-out doses. The deficiencies were identified through review of facility policy, clinical records, a facility investigation, and staff interviews. The findings demonstrate that the facility did not adhere to its own policies and procedures for the documentation and accounting of controlled substances, resulting in unaccounted-for medications and incomplete records for the residents involved.