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Based on document review, record review and interview, the facility failed to ensure that medications are administered by the order of a physician. Findings include:

During review of the controlled substance log dated 03/18/2012, it revealed that patient #1 had been administered a 0.5 mg Ativan tablet. The medical record for patient #1 did not contain an order from a physician for the medication. The medication sheets for the patient lacked documentation of the medication being administered. The controlled substance log did not contain an incorrect count from the AM shift to the PM shift.

During interview with the pharmacist on 03/19/2012 at 1500, she confirmed the findings and was unaware of a discrepancy in the controlled substances.