Failure to Accurately Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accurate reconciliation and documentation of controlled medications administered to two residents. For one resident admitted with a right humerus fracture, physician orders indicated oxycodone was to be administered as needed for moderate to severe pain. However, review of the narcotic sheet and electronic Medication Administration Record (MAR) for May 2025 showed that oxycodone was removed from the medication cart on several occasions, but the administration was not documented on the MAR for multiple dates. Licensed staff confirmed that the expected practice was to sign both the narcotic sheet and the MAR when administering narcotics, but this was not consistently done. Similarly, another resident with a diagnosis including urinary tract infection had an order for acetaminophen-hydrocodone (Norco) as needed for pain. The narcotic sheet indicated that Norco was removed from the medication cart on several dates, but these administrations were not documented on the MAR. Interviews with staff, including the Infection Preventionist and the Director of Nursing, confirmed that facility policy required documentation on both the narcotic sheet and the MAR, which was not followed. The facility's policy on controlled substances outlined the need for immediate and accurate record-keeping, which was not adhered to in these cases.