Failure to Document Narcotic Administration by Licensed Staff
Penalty
Summary
The facility failed to ensure that the Narcotic and Hypnotic Record included the required signatures of licensed nursing staff to document the administration of controlled medications for one of seven medication carts. Specifically, on the date reviewed, there were no licensed staff initials in the designated signature boxes for the administration of Tramadol to one resident and Hydrocodone to another resident. The responsible LVN confirmed that she had not documented the administration of these medications immediately after giving them, as required by facility policy. Both residents involved had significant medical conditions, including heart failure and respiratory failure, and were dependent on staff for personal care and hygiene. The Director of Nursing confirmed that licensed staff are responsible for immediate documentation after medication administration to prevent errors. Review of the facility's policy indicated that the administering staff must record their signature and title in the resident's medical record as required.