Failure to Document Controlled Medication Administration on MAR
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its own policies and procedures for one resident. Specifically, the facility's policy required that when a controlled medication is administered, the licensed nurse must immediately document the date and time of administration, the amount administered, and their signature on the accountability record, as well as ensure all current drug and dosage schedules are recorded on the resident's electronic medication administration record (eMAR). For one resident, there was a physician's order for hydrocodone-acetaminophen to be administered as needed for pain. On a specific date and time, one tablet of this controlled medication was dispensed and signed out on the Narcotic and Hypnotic Record. However, review of the resident's July medication administration record (MAR) did not show documentation that the hydrocodone-acetaminophen was administered at the recorded time. This omission was verified during an interview and concurrent medical record review with the Director of Nursing (DON). The lack of documentation on the MAR was not in accordance with the facility's established policies for controlled medication administration and record-keeping.