Failure to Accurately Document Controlled Substance Administration and Inventory
Penalty
Summary
The deficiency involves the facility’s failure to accurately document controlled substance administration on individual narcotic record sheets in accordance with its policy. During an observation of a medication cart serving 18 residents, an LPN stated she had not documented the controlled medications administered that morning in the controlled medication binder. Review of the binder and comparison with blister card counts for six residents showed consistent discrepancies: for each resident, the number of pills recorded as remaining in the controlled medication binder was one higher than the actual number of pills remaining in the blister card. This included pregabalin and hydrocodone-acetaminophen for one resident, tramadol for two residents, lorazepam for one resident, hydrocodone-acetaminophen for another resident, and clonazepam and pregabalin for a sixth resident. The residents involved had various medical conditions, including severe cognitive impairment, seizure disorder, depression, Parkinson’s disease, coronary artery disease, cerebrovascular accident history, anemia, hypertension, chronic obstructive pulmonary disease, neurogenic bladder, hyperlipidemia, type 2 diabetes mellitus, pain, and cardiomyopathy. Interviews with the Unit Manager and DON confirmed that the expectation and written policy required nurses to document controlled drug administration immediately after dosing, including date, time, dose, nurse signature, and remaining doses. The observed discrepancies and the LPN’s admission that she had not documented the morning controlled medication administrations demonstrated noncompliance with the facility’s controlled substance management policy.
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