Failure to Accurately Administer and Document Narcotic Pain Medication
Penalty
Summary
Nursing staff failed to accurately administer and document narcotic pain medications for a resident with chronic pain and multiple comorbidities, including chronic ulcers, heart failure, respiratory failure, and end-stage renal disease. The resident was prescribed Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for moderate to severe pain. However, review of the Individual Narcotic Record (INR) and Medication Administration Record (MAR) revealed inconsistencies, including documentation errors, missing signatures, and lack of clarity regarding medication administration. On multiple occasions, the INR showed that a tablet was removed and marked as an error without proper explanation or required signatures, while the MAR indicated the medication was given. Further investigation revealed that the resident was administered the incorrect dosage of Hydrocodone-Acetaminophen (5-325 mg instead of the prescribed 10-325 mg) on at least nine occasions over a nine-day period. The error occurred due to the presence of both old and new medication packs in the medication cart, and nursing staff failed to verify the correct strength before administration. The facility's policies required adherence to the seven rights of medication administration and proper documentation and reporting of medication errors, but these procedures were not followed in this case. Additionally, there was no evidence that medication errors were reported to the Director of Nursing, the attending physician, or the resident's responsible party as required by facility policy. The resident's responsible party was unaware of the medication errors and reported that the resident continued to experience significant pain. The lack of proper documentation, communication, and adherence to medication administration protocols resulted in multiple medication errors and inadequate pain management for the resident.