Failure to Document Narcotic Medication Administration in MARs
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) accurately reflected the administration of narcotic medications for three residents. For one resident with diagnoses including anxiety, diabetes, and chronic pancreatitis, the MAR did not document the administration of prescribed Xanax and oxycodone, despite the controlled substance record indicating these medications were given on multiple occasions. Similarly, another resident with depression and rheumatoid arthritis received Tramadol as documented in the controlled substance record, but the administration was not recorded in the MAR for both March and April. A third resident with a left femur fracture and osteoarthritis was administered hydrocodone-acetaminophen, as shown in the controlled substance record, but the MAR lacked corresponding documentation. Interviews with staff confirmed that the MAR should be signed when narcotic medications are administered. The Director of Nursing provided a policy stating that administration of controlled substances must be recorded in both the MAR and the controlled substances inventory record at the time of administration. Despite this policy, the required documentation was missing from the MARs for all three residents, as observed during the review.