Inadequate Controlled Drug Record Keeping
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate records for the dispensing and administration of controlled drugs. This deficiency was identified through interviews and record reviews for three residents. For Resident #487, there was a discrepancy between the Medication Monitoring/Control Record and the Medication Administration Record (MAR), where a medication was signed out as removed from the medication cart but not documented as administered. Similarly, for Resident #28, a medication was removed from the cart but not recorded as administered on the MAR. In contrast, for Resident #82, a medication was documented as administered but not signed out as removed from the medication cart. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) Unit Manager revealed that the Unit Managers are responsible for auditing the medication reconciliation of controlled substances. The LPN Unit Manager stated that she checks the Medication Monitoring/Control Record against the MAR to ensure all entries are signed and match, typically performing this audit three times a week, although it is supposed to be done once a week. These findings indicate a failure in the facility's system to accurately record and reconcile the receipt and disposition of controlled drugs, as required by the consultant pharmacist's established system.
Plan Of Correction
N092 FAC CONTROLLED DRUGS - RECORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #487, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2) In the allegation of Resident #28, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 3) In the allegation of Resident #82, the resident's medication was not signed out but was documented as administered. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Penalty
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