Failure to Accurately Document Narcotic Administration
Penalty
Summary
The facility failed to ensure that the medication administration records accurately reflected the administration of narcotics for two residents. In the first instance, a medication card for hydrocodone-acetaminophen showed 11 tablets remaining, while the controlled substances record indicated 12 tablets. The last documented administration was by a qualified medication aide, but the nurse who administered the medication later stated she had forgotten to sign out the narcotic after giving it. The resident involved had multiple diagnoses, including osteoarthritis, neuropathy, and cognitive impairment, and was unable to communicate pain levels. In the second instance, discrepancies were found in both hydrocodone-acetaminophen and pregabalin counts for another resident. The medication cards showed fewer tablets and capsules than the controlled substances records indicated. The last administrations were documented by LPNs, who later acknowledged that they had not signed out the narcotics at the time of administration, contrary to facility policy. This resident also had significant medical history, including recent knee replacement, chronic pain conditions, and moderate cognitive impairment. Facility policy required controlled substances to be documented in both the MAR and the controlled substances inventory record at the time of administration, which was not followed in these cases.