Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, documentation of the administration of hydrocodone-acetaminophen (Norco) was missing from the electronic medical record (MAR) for several dates, despite the medication being signed out on the controlled drug record. Multiple nurses, including LVNs, administered the medication but did not consistently document the administration in the electronic medical record as required by facility policy. Interviews with nursing staff confirmed that the medication was given but not always recorded in the MAR, with one LVN admitting to forgetting to document after administration. The resident involved was a cognitively intact male with diagnoses including metabolic encephalopathy, anxiety disorder, and acute kidney failure, and had a care plan for pain management that included active participation in care decisions. The resident reported that his pain was well controlled and that the medication was essential for him. The facility's policy required documentation of medication administration in the MAR after the resident took the medication, but this was not consistently followed, resulting in incomplete medical records for the resident.