Failure to Accurately Document PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident prescribed Oxycodone Hydrochloride (HCL), a controlled opioid medication. A physician's order specified that the resident was to receive Oxycodone HCL 5 mg every six hours as needed for moderate to severe pain. Review of the narcotic controlled substance count record showed that a nurse signed out doses of Oxycodone on multiple dates. However, corresponding entries were missing from the Medication Administration Record (MAR) for each of those instances, indicating that the medication was not documented as administered in the resident's medical record. During interviews, the nurse involved could not recall whether she had documented the administration of the medication on the MAR for the dates in question. The Director of Nursing (DON) confirmed that the expectation was for nursing staff to document medication administration accurately and promptly after giving the medication. The discrepancy between the narcotic count sheet and the MAR demonstrated a failure to maintain accurate and complete medical records in accordance with accepted professional standards.