Failure to Ensure Accurate Documentation and Staff Competency in Narcotic Administration
Penalty
Summary
The facility failed to ensure staff competency in the administration and reconciliation of narcotic pain medications for two residents. During a medication storage observation, discrepancies were found between the narcotic log and the electronic medication administration record (EMAR) for as-needed (PRN) doses of tramadol and oxycodone. For one resident with an internal joint prosthesis infection and above-knee amputation, the narcotic log showed multiple PRN doses administered, but the EMAR lacked documentation for several of these doses. Similarly, for another resident with a right humerus fracture, diabetes, and hypertension, the EMAR did not reflect all doses recorded in the narcotic log, and some doses were not documented in both records as required. Interviews with nursing staff revealed inconsistent practices regarding documentation, with some staff admitting to not always recording narcotic administration in both the MAR and the narcotic log due to time constraints or lack of clarity on how to document late or amended administrations. The facility's policies require that all controlled substances be documented in both the MAR and the narcotic log, and that the records match. However, audits and staff interviews confirmed that this was not consistently followed, leading to incomplete and inaccurate records for narcotic administration.