F0842

D

Incomplete Controlled Substance and MAR Documentation for a Resident

Snow Hill, Maryland Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident, specifically related to controlled substances and medication administration documentation. During a complaint survey, a nurse surveyor reviewed the closed medical record of Resident #3 and requested all closed paper documents and access to the electronic medical record. Several documents were found to be missing from the clinical record, and facility staff were unable to produce certain documentation, including medication administration records (MARs) and controlled medication records. The nursing staff did not document the number of Oxycontin 10 mg tablets destroyed on the resident’s controlled substance administration record on 09/21/25.

In an interview on 02/04/26, the DON stated they were unable to locate the resident’s Oxycodone controlled substance administration record for dates between 09/05/25 and 09/24/25. Additionally, a review of the resident’s Oxycodone 5 mg tablet MAR for August and September 2025 showed missing nursing administration signatures and nursing assessments for doses that were given on specific dates and times, including 08/25/25 at 4 pm, 09/01/25 at 10:30 pm, and 09/02/25 at 1:15 pm and 6:15 pm. The report notes that documentation is an integral part of medication administration and that inaccurate medication documentation has the potential to place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers to evaluate.