Failure to Accurately Document Pain Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records regarding the administration of pain medication for one resident with a history of a left lower leg fracture, bilateral primary osteoarthritis of the knees, and polyneuropathy. The resident, who was cognitively intact, had an active order for Percocet 10-325 mg to be given every four hours as needed for moderate to severe pain. Documentation review revealed a significant discrepancy: while the Medication Administration Record (MAR) showed that the medication was administered 37 times over a two-week period, the narcotic record indicated that 73 pills were signed out during the same timeframe. Interviews with nursing staff confirmed that medications were sometimes signed out on the narcotic record but not consistently documented on the MAR. Nurses acknowledged the importance of accurate documentation on both records, as the MAR is used by physicians to monitor medication administration and make necessary adjustments. Facility leadership, including the ADON and DON, also emphasized the need for proper documentation to ensure an accurate record of what medications residents receive. The failure to consistently document administration of pain medication on the MAR resulted in an inaccurate medical record for the resident.