Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of narcotic pain medication. Specifically, for a resident with diagnoses including right upper arm pain and low back pain, the July and August medication administration records did not document the administration of Oxycodone IR 5 mg, despite the controlled drug administration record indicating that the medication was given on multiple occasions. The MAR lacked documentation for the administration of the resident's medication from July through early August, even though the controlled drug record showed the medication was dispensed at those times. Interviews with staff confirmed that both the controlled drug administration record and the MAR should be signed by the nurse when administering routine or as-needed narcotic pain medication. The facility's policy, as provided by the Director of Nursing, states that medications will be charted when given and narcotics will be signed out when administered. The failure to document the administration of narcotic medication on the MAR was identified during a review of the clinical record and confirmed through staff interviews.