Failure to Account for and Document PRN Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident prescribed Methocarbamol 500 mg as a PRN medication for pain management. Over a period of several months, there was a significant discrepancy between the number of Methocarbamol tablets received from the pharmacy and the number documented as administered in the Medication Administration Records (MARs). Specifically, the records showed that far fewer doses were documented as given than the number of tablets supplied, resulting in a large number of pills unaccounted for. The resident involved had a history of dementia and pain in the left knee, and was cognitively intact according to assessment. The resident reported receiving medications as needed and did not experience any instances where medication was unavailable or pain was uncontrolled. However, the facility's documentation practices were inconsistent, with staff interviews revealing that PRN medications were sometimes administered but not always documented. The issue was identified when the pharmacy consultant noted that a refill request for the muscle relaxer was made earlier than expected, prompting a review that uncovered the missing documentation and unaccounted pills. Interviews with facility staff, including the DON, ADM, and several nurses, confirmed that muscle relaxers were not routinely counted or tracked like controlled substances, and that there was a lack of consistent documentation for PRN medication administration. The discrepancy was attributed by facility leadership to documentation errors, but there was no direct evidence to confirm whether the medication was actually administered or diverted. The facility's policies required accurate documentation and secure storage of medications, but these procedures were not followed in this instance, leading to the deficiency.