Failure to Accurately Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurately documented regarding the administration of narcotic medications for three residents. Specifically, there were discrepancies between the narcotic administration log and the Medication Administration Records (MAR) for these residents. For one resident with lumbar spinal stenosis and cognitive communication deficit, the narcotic log showed that oxycodone was administered, but this was not documented in the MAR. Another resident with spondylolisthesis had two doses of oxycodone recorded in the narcotic log, but these were not reflected in the MAR. A third resident with encephalopathy and multiple cancerous tumors also had a dose of oxycodone documented in the narcotic log but not in the MAR. These documentation failures were identified following a facility-reported incident in which two alert and oriented residents reported not receiving their PRN narcotic pain medication after multiple requests. The discrepancies were confirmed during a review of the records and acknowledged by the Director of Nursing Services. The lack of proper documentation in the MAR for administered narcotic medications was not in accordance with accepted professional standards and facility policy.