Failure to Ensure Accurate Documentation and Handling of Controlled Substances
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for three of eight residents reviewed. For one resident with chronic pain and moderate cognitive impairment, a registered nurse administered Hydrocodone-Acetaminophen as ordered but did not document the administration on the resident's narcotic sheet. This discrepancy was identified during shift change when the narcotic count did not match the number of medications in the cart. The nurse admitted that documentation was sometimes missed due to being busy, but confirmed the medication was given. Another resident with chronic pain, cancer, and moderate cognitive impairment had Tramadol administered by an LVN, but the administration was not documented in the Medication Administration Record (MAR) on two occasions, despite being recorded on the narcotic sheet. The LVN acknowledged forgetting to document in the MAR due to workload and recognized the importance of accurate documentation to track medication administration and prevent errors. A third resident with severe cognitive impairment and anxiety had a blister pack of Lorazepam punctured, but instead of wasting the dose as required, the pack was taped shut. Staff were unsure of the correct procedure, but another nurse clarified that punctured narcotic blister packs should be destroyed and witnessed by two nurses. The facility's policies required immediate removal and destruction of compromised medications and proper documentation of all administered and wasted controlled substances.