Medication Administration and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to provide routine and as-needed medications as prescribed by physicians for three residents, and did not ensure controlled drugs were accurately accounted for or timely discarded for two residents. Specifically, medication administration records (MARs) showed that prescribed doses of controlled pain medications such as morphine sulfate and oxycodone were not properly documented as being removed from the controlled drug box or signed out in the controlled drugs logbook. In one instance, a resident received a dose of oxycodone from another resident's supply, and the discontinued medication was not destroyed as required. Additionally, discrepancies were found between the actual amounts of controlled substances in medication bottles and the amounts recorded in the controlled substance record book. For example, a bottle of liquid morphine sulfate had more medication remaining than what was documented, and staff could not account for the difference. Staff interviews confirmed that controlled drug counts were not always accurate and that discontinued medications were not destroyed in a timely manner. The facility also failed to document medication administration in accordance with professional standards. In one case, an LPN documented that a resident received their scheduled medication before it was actually administered. The resident subsequently left the facility for a medical appointment without taking the medication, but the electronic MAR still reflected that the dose had been given. Staff acknowledged that documentation should only occur after administration, and that the error would need to be corrected in the record.