Failure to Follow Controlled Substance Documentation Standards and Correctly Transcribe IV Hydration Order
Penalty
Summary
The deficiency involves failures in controlled substance administration and documentation, as well as incorrect transcription and implementation of a physician’s order. During a morning medication pass, an LPN prepared and administered Ativan 0.5 mg for a resident by removing one tablet from the locked controlled medication drawer and adding it to the resident’s other morning medications. The LPN did not verify the current Ativan count, did not document the dose removed on the controlled count sheet at the time of removal, and proceeded to prepare and administer medications for three additional residents without signing out the Ativan dose. When interviewed, the LPN stated they sign for controlled medications after completing all morning medication administrations and indicated that some nurses sign when removing the pill and others after finishing the medication pass. Facility policy on controlled substance administration and accountability requires that each dose administered be recorded, subtracted from the previous count, and the remaining amount documented. The deficiency also includes a failure to correctly transcribe and carry out a physician’s order for IV hydration for another resident with chronic diastolic heart failure, stage 3 chronic kidney disease, and severe cognitive impairment. A progress note documented that this resident was lethargic, difficult to arouse, with low blood pressure, but responsive to verbal stimuli and sternal rub, and with stable vital signs otherwise. The physician was notified and gave STAT orders for labs (CBC with diff, CMP, UA/urine culture), IV hydration with 0.9% normal saline at 70 cc/hr for one liter, and vital signs every six hours for 24 hours. However, the IV fluid order was transcribed in the medical record with an incorrect start date, setting the infusion to begin the following day instead of the same day, which created a delay in medical treatment. Attempts by surveyors to contact the nurse who transcribed the order were unsuccessful, and the regional nurse consultant could not explain why the order was not transcribed correctly.
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