Complaint Investigation Report

Based on interviews staff 1 to 6 (S1–S6), the facility keeps separate binders for controlled substances and the Medication Administration Record (MAR). When controlled medications arrive, two staff record, count, and log them before storing them in a locked cabinet. When dispensing, staff initial the controlled substance binder and note the medication on the MAR. Most controlled medications are PRN. At shift change, two staff recount and initial the log.

Based on record review and interview, staff corrected record entry by crossing out, initialing, and updating both the MAR and narcotics binder.

S1 stated that controlled medications are stored on-site, and clients typically know their medication schedules. Three clients currently have controlled prescriptions. Controlled medications are stored securely at the facility. Clients generally know when and which medication they need to take. All staff can dispense medications upon client request and log the administration in front of the client. All staff are authorized to hand over medication requested by clients.

S2 stated that the program administrator revised procedures so medication administration is logged only on the MAR, while the controlled binder tracks inventory counts. However, S2 admitted logging a dose in the binder but not on the MAR, leading another staff to administer the same medication later that day but not at the same hour.

Based on document review and interview, the facility is using old and new forms, resulting in errors in recording medications correctly. Staff previously signed only the controlled substance binder, creating an error. A new policy was placed that requires staff signing the MAR at shift end to prevent early dosing. To prevent recording errors.

S3 stated that staff generally follow doctor’s orders, with rare minor errors such as missed documentation or incorrect RX numbers. Medication records should include count, reason for administration, and staff signature. Controlled substances are logged with client name, initial count, and time administered. Clients request PRNs before administration, and errors are corrected promptly. S3 did not witness any wrong medication being given.