Failure to Document PRN Pain Medication Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document the administration of Hydrocodone-Acetaminophen (Norco) for a resident who was cognitively intact and required some assistance with activities of daily living. The resident, who had diagnoses including Metabolic Encephalopathy and Type 2 Diabetes Mellitus, reported receiving a dose of Norco around 9 a.m. on the specified date. Upon review, the LVN confirmed administering the medication but did not document it at the time, stating that he became occupied with another resident and forgot to complete the documentation. The facility's policy and procedure for medication administration required that medications be administered by licensed nurses as ordered and that the Medication Administration Record (MAR) be signed immediately after administration, ensuring the six rights of medication administration, including right documentation. The Director of Nursing confirmed that nurses are expected to document medication administration immediately after giving the medication to prevent errors.