Failure to Maintain Accurate Narcotic Logs and Medication Administration Records
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate narcotic logs and medication administration records for two residents on the 500 Hall medication cart. For one resident with a history of hip and knee replacement and moderately impaired cognition, the narcotic administration record for Acetaminophen-Codeine showed a discrepancy of one pill between the log and the blister pack. The medication was last administered in the morning, but the count did not match the record. For another resident with pain and intact cognition, the narcotic administration record for hydrocodone-acetaminophen also showed a one-pill discrepancy, with the log indicating one less pill than the blister pack. The medication was signed off as given, but the resident reported not receiving it until later when the nurse realized the omission. Interviews with the nurse responsible revealed she was unaware of the discrepancies and admitted to forgetting to log one administration and to signing off for a medication that was not actually given. The nurse acknowledged the importance of reconciling counts and logging medications immediately after administration, as per facility policy and training. The DON confirmed that staff are expected to document administration on both the medication administration record and the narcotic log, and that counts should be reconciled at each shift change. Review of facility policy and training materials supported these expectations.