Unaccounted and Undocumented Controlled Medications for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and account for a hospice resident’s controlled pain and anxiety medications, resulting in misappropriation concerns and undocumented administration. The resident had multiple diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, cerebral infarction, and severe cognitive impairment, and was non-verbal with staff-assessed indicators of pain such as non-verbal sounds and facial expressions. The resident’s care plans called for consistent pain assessment, administration of ordered pain medications (including Oxycodone, Tylenol, Ibuprofen, Gabapentin, and later Morphine and Ativan), observation for side effects, and close collaboration with hospice to provide maximum comfort. Record review showed significant discrepancies between the MARs and narcotic control sheets for Oxycodone, Ativan, and Morphine. For Oxycodone 5 mg, the narcotic control sheet indicated 60 tablets received, with 27 remaining on one date and only one tablet documented as disposed of later, but there was no narcotic control sheet documentation for 16 doses that were recorded as administered on the MAR over several days. Reconciliation indicated there should have been 11 tablets remaining if the MAR entries were accurate, and the Administrator and DON confirmed there was no control sheet to account for the 27 tablets previously remaining. For Ativan 0.5 mg, multiple doses were signed out on the narcotic control sheet on several dates but were not documented on the MAR, and several refused doses were signed out on the control sheet without any evidence of wastage. Later, when the Ativan dose was changed to 1 mg scheduled and PRN, two tablets were removed per the control sheet but not documented on the MAR. For Morphine Sulfate, the resident had PRN orders that were later increased in dose and frequency, yet the narcotic control sheet showed multiple administrations on different dates that were not signed off on the MAR, and on another date several 0.5 ml doses were removed without the nurse signing the control sheet. The facility’s medication administration policy required recording dose, route, and time on the MAR, which was not followed in these instances. Anonymous staff interviews indicated the resident’s daughter was upset because a nurse would not administer pain medication per hospice orders, and the DON and Administrator confirmed the reconciliation findings, including that a nurse did not sign off Morphine on the control sheets on a specific date. The resident’s daughter also reported that her mother did not receive pain medication as ordered by hospice.
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