Inaccurate Documentation of Narcotic Administration
Penalty
Summary
The facility failed to accurately document the administration of narcotic medications for two residents. For one resident with encephalopathy and moderate cognitive impairment, there was an active order for Lorazepam 0.5mg as needed. Documentation discrepancies were found between the paper Medical Monitoring/Control Record (MMCR) and the electronic Medication Administration Record (MAR), including a dose recorded on the MMCR but not on the MAR, and mismatched administration times between the two records. The nurse responsible admitted to making errors in documenting the date and time of administration. For another resident with hemiplegia and a history of cerebral infarction, who was cognitively intact, there was an active order for Lacosamide 100mg twice daily for seizures. The MMCR showed three administrations of Lacosamide on one day and one on the following day, while the MAR reflected only two administrations on the first day and one on the second. The nurse involved acknowledged a mistake in documenting the date on the paper narcotic log, stating she did not work on the day in question. The DON confirmed the discrepancies and agreed that accurate documentation is essential, especially for narcotics.