Failure to Accurately Document and Administer Pain Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse failed to accurately document the administration of a controlled medication, oxycodone/APAP 10/325 mg, for a resident. During an inspection of the medication cart, it was found that the narcotic and hypnotic record indicated seven doses remaining, while the medication card contained only six. The nurse admitted to dispensing the missing dose earlier in the day but did not sign the narcotic record at the time of administration, contrary to facility policy which requires immediate documentation upon removal of the medication from the bubble pack. Another deficiency was identified in the administration of a lidocaine patch for pain management for a different resident. The resident, who had a history of cauda equina syndrome, generalized muscle weakness, and polyosteoarthritis, reported not receiving her prescribed lidocaine patch for shoulder pain. Upon review, it was found that the patch had not been applied as ordered, and the electronic medication administration record (eMAR) incorrectly indicated that the medication had been administered. The nurse responsible had not completed the required self-administration assessment for the resident, which is necessary before a resident can self-administer medication. Interviews with nursing staff and review of facility policies confirmed that medications are to be administered and documented as prescribed, and that pain management interventions should be consistent with the resident's care plan and physician orders. The failure to follow these procedures resulted in the resident not receiving timely pain management and the lack of proper documentation and assessment for self-administration of medication.