Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was prescribed narcotic pain medication. Specifically, the resident, who had diagnoses including cervical disc degeneration, bilateral primary osteoarthritis of the knee, and chronic pain syndrome, was observed to be in pain and requested pain relief. The resident had a physician's order for Morphine Sulfate Solution to be administered as needed for pain. Upon review, it was found that although the Narcotic Record Book documented administration of Morphine on multiple occasions, these administrations were not signed out as given on the Medication Administration Record (MAR). Interviews with staff confirmed that the resident received pain medications, and the narcotic record indicated doses were given. However, both the LPN and the Unit Manager acknowledged that the administration of Morphine was not documented on the MAR as required. The failure to sign out the medication on the MAR resulted in incomplete and inaccurate medical records for the resident.