Incomplete and Inaccurate Documentation of Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for six residents who were receiving PRN opioid pain medications. Staff did not consistently document the administration of narcotic medications on both the Medication Administration Record (MAR) and the Controlled Drug Record as required. In several instances, medication administrations were recorded on the Controlled Drug Record but not on the MAR, and vice versa. Additionally, there were discrepancies between the physician’s orders and the instructions on the Controlled Drug Record, such as mismatched dosing intervals. For multiple residents, including those with intact cognitive function and ongoing pain management needs, the documentation failures included missing entries for administered doses, late documentation, and missing pages from Controlled Drug Records. In some cases, the Controlled Drug Record was incomplete or could not be reconciled due to missing documentation. Interviews with staff, including the DON and a nurse practitioner, confirmed that staff were expected to document all narcotic administrations on both the MAR and Controlled Drug Record, and that these records were used to assess pain management and medication usage. The lack of accurate and complete documentation affected the ability to track medication administration and ensure orders were followed as written. The DON and other staff acknowledged the missing or inconsistent documentation and the inability to reconcile records due to missing pages. These deficiencies were observed across all six residents reviewed for misappropriation of property, with specific examples of undocumented or mismatched medication administrations detailed for each resident.