Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain accurate clinical records for one resident by not properly documenting the administration of Oxycodone Hydrochloride on the Medication Administration Record (MAR). Specifically, the Controlled Drug Record showed that Oxycodone was signed out and administered by two different Licensed Vocational Nurses on two occasions, but these administrations were not recorded on the MAR. The Director of Nursing confirmed that medication administration should be documented on the MAR immediately after the medication is given and that the MAR entries should align with the Controlled Drug Record. The resident involved had multiple diagnoses, including a right femur fracture, type 2 diabetes, end stage renal disease, and muscle weakness, and was assessed as having intact cognition and decision-making capacity. Facility policy required that all administered medications be documented on the MAR by the person administering them, and that the MAR be reviewed at the end of each medication pass to ensure accuracy. The failure to document the administration of a controlled substance as required by policy and professional standards constituted the deficiency.