Incomplete and Inaccurate Documentation of Narcotic Administration
Penalty
Summary
The facility failed to ensure that medical records for a resident were accurate and complete, specifically regarding the documentation of administered narcotic pain medication. A review of the resident's records showed discrepancies between the Medication Administration Record (MAR) and the Narcotic Flow Record (NFR). On several occasions, an LPN documented the administration of oxycodone on the NFR but did not record it on the MAR, and vice versa. Another LPN also documented administration on the NFR without corresponding documentation on the MAR. These inconsistencies meant that the resident's medical record did not accurately reflect the administration of narcotic pain medication. The resident involved had severe cognitive impairment and multiple serious diagnoses, including malignant neoplasm of the breast, neoplasm of the lung, and primary osteoarthritis. The discrepancies were confirmed by the Director of Nursing, who acknowledged that the medical record did not accurately reflect the medications administered. The issue was identified during a review of records and interviews conducted as part of the survey process.