Inaccurate Documentation and Discrepancies in Controlled Substance Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate records and documentation for controlled medications for multiple residents. For one resident with an order for hydrocodone-acetaminophen (Norco) 5-325 mg every four hours as needed for pain, a narcotic count showed 14 pills remaining in the punch card, while the Controlled Drug Receipt/Record/Disposition Form indicated 15 pills remaining with the last documented dose given several days earlier, leaving one tablet unaccounted for. The LPN who participated in the narcotic count stated she had counted with the previous nurse, did not know why there was a discrepancy, and did not remember administering the medication. Another resident had an order for alprazolam 0.25 mg twice daily and every 12 hours as needed; the controlled drug record showed a tablet removed and documented as given for another resident, while that resident’s MAR did not show administration of alprazolam on that date. For a third resident, the Controlled Drug Receipt/Record/Disposition Form showed Norco signed out twice on the same day without any staff member’s name recorded, and the MAR showed that the resident did not receive Norco on that date. Additionally, controlled substance sheets for four other residents were signed off by the same LPN during a narcotic count, and the LPN stated she had administered the controlled substances but had not signed them out on the controlled substance sheets, even though the MARs showed the medications were scheduled for administration earlier that morning. Staff interviews confirmed that narcotics are supposed to be counted at shift change by two nurses, with one reviewing the book and the other the cart, and that medications should be documented at the time they are given. Facility policies required the individual administering medications to initial the MAR after each administration and mandated end-of-shift controlled substance counts with documentation and reporting of discrepancies to nursing leadership.
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