Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to maintain accurate and orderly drug records and did not ensure that all controlled drugs were properly accounted for and periodically reconciled, as required by policy and state regulations. Specifically, for two residents receiving oxycodone for pain management, there were discrepancies between the number of medication containers and controlled drug record sheets during shift changes, with missing signatures and unexplained differences in counts. On several occasions, the number of medication containers did not match the number of record sheets, and staff were unable to explain these inconsistencies during interviews. Additionally, there were mismatches between the Medication Administration Records (MARs) and the Controlled Drug Record sheets for both residents. Doses of oxycodone were documented as administered on the Controlled Drug Record sheets but were not reflected on the MARs, and vice versa. The Director of Nursing was unable to provide explanations for these discrepancies. These findings indicate that the facility did not follow its own policy for controlled substance management and failed to maintain an accurate account of controlled drugs for the residents involved.