Failure to Ensure Timely and Accurate Documentation of Narcotic Medications
Penalty
Summary
The provider failed to ensure professional nursing standards of practice regarding the timely and accurate documentation of narcotic medications for two residents. Multiple instances were identified where Hydrocodone-Acetaminophen tablets were signed out on the narcotic sign-out sheet by registered nurses but were not documented as administered in the medication administration record (MAR) at the same time, or in some cases, not documented at all. There were also discrepancies in the timing of documentation, with one dose not recorded in the MAR until several hours after it was signed out. Additionally, one instance was noted where a narcotic tablet was removed without a time of removal, and the administration was documented by a different nurse at an earlier time than the removal. For another resident, a narcotic tablet that was dropped was not properly documented as wasted, as it lacked a second nurse's signature to verify the destruction of the medication. Interviews with nursing staff and the director of nursing confirmed that the facility's expectation and policy require that narcotic medications be documented in the MAR at the same time they are signed out on the narcotic sign-out sheet, and that any wasted narcotics must be verified by two nurses. Review of the facility's Controlled Substances policy further supported these requirements, stating that the controlled substance sheet and eMAR must match and that proper record keeping is essential. The observed failures in documentation and verification did not align with these established standards and policies.