Lack of Documentation for Signed-Out Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accountability and documentation for controlled medications for three cognitively intact residents with pain-related conditions. Facility policy dated May 14, 2025, required nursing staff to record and sign the medication, dosage, and time of administration on each resident’s medication record immediately after administration. For one resident with chronic back pain related to spinal stenosis and discitis, physician orders dated October 20, 2025, prescribed Percocet 5-325 mg every six hours as needed. The controlled drug record for October 2025 showed Percocet tablets signed out on October 24 at 3:30 p.m. and October 25 at 9:00 a.m., but there was no corresponding documentation on the MAR or elsewhere in the clinical record that these doses were administered. A second resident, cognitively intact with spinal stenosis, diabetic neuropathy, recent hospice admission, and an opioid regimen, had a physician’s order dated January 10, 2026, for Morphine 10 mg sublingual every two hours as needed for pain or respiratory distress. The January 2026 controlled drug record showed Morphine 10 mg doses signed out on January 10 at 8:00 a.m., 12:00 p.m., and 4:00 p.m., with no documented evidence on the MAR or in the clinical record that these doses were given. A third cognitively intact resident with occasional pain and on routine and PRN pain medications, including an opioid, had an order dated December 29, 2025, for Percocet 5-325 mg every 12 hours as needed. The controlled drug record for late December 2025 and January 2026 showed Percocet tablets signed out on December 28 at 6:15 p.m. and January 5 at 10:30 a.m., again without documentation in the MAR or clinical record that the doses were administered. In an interview on January 14, 2026, at 3:57 p.m., the DON confirmed there was no documented evidence in the three residents’ records that the signed-out narcotic doses were administered at the recorded dates and times.
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