Failure to Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to ensure that the administration of a narcotic pain medication, morphine sulfate solution, was consistently documented on the medication administration record (MAR) for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, osteoporosis, uterine cancer, and chronic pain. The resident, who had transitioned to hospice care, had a physician's order for morphine to be administered as needed for pain or dyspnea. Review of the MARs for September, October, and December 2024 showed that not all doses of morphine signed out on the controlled drug record were documented as administered on the MAR. For example, doses were signed out on the controlled drug record on several dates, but corresponding documentation was missing from the MAR on those same dates. Interviews with the Director of Nursing confirmed that medications must be documented on the MAR when given, and verified the discrepancies between the controlled drug records and the MARs for the resident. Facility policy also requires that medications be documented on the MAR as soon as they are administered. The failure to document the administration of morphine as required by policy and physician order resulted in incomplete records for the resident's pain management.