Inaccurate Documentation and Handling of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication administration records (MARs) and controlled drug count sheets accurately reflected the disposition of controlled medications for multiple residents. Facility policy required that each dose of medication be properly recorded on the MAR and that when a CMA was unable to administer a medication, the charge nurse be notified immediately. For one resident with an order for Norco 10-325 mg every four hours as needed for pain, comparisons between the February MAR and the individual narcotic record from late January to late February showed repeated discrepancies: on multiple dates, the narcotic record reflected more doses signed out than were documented as administered on the MAR, with no notation that the unaccounted tablets were destroyed. The resident reported they kept their own notes on pain pill use and, when compared to the facility’s narcotic records, found the records were not accurate. A second resident had an order for Ativan 1 mg at bedtime. Review of the February MAR and the corresponding narcotic record showed that on numerous dates the narcotic record indicated a dose was administered, while the MAR documented that the dose was refused. There was no documentation on the narcotic record that the refused tablets were destroyed. On another date, the MAR showed the medication was administered, but no dose was signed out on the narcotic record. An additional undated narcotic entry, located after a late-February entry, showed a dose as administered while the MAR documented a refusal for that same time frame, again without any destruction notation. A third resident had an order for tramadol 50 mg, two tablets every six hours as needed for pain. For this resident, the narcotic record showed two tablets administered on a specific February date, while the MAR showed no tramadol doses given that day and there was no documentation that the tablets were destroyed. During interviews, CMAs and nursing staff acknowledged that the MARs and narcotic records for these residents were inaccurate and showed pills signed out without documentation of administration or destruction. Staff described that refused controlled medications were supposed to be taken to the charge nurse and destroyed together with both parties initialing the count sheet, but one CMA reported they had been destroying refused medications alone without notifying the nurse, contrary to the described procedure. The DON stated that some CMAs had not been following the procedure to alert charge nurses of refused narcotics and to jointly destroy and document them.
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