Failure to Accurately Document and Account for Narcotic 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 three residents across three medication carts. Specifically, the narcotic counts on the medication carts for these residents did not match the actual number of pills in the blister packs. For example, the narcotic administration records for hydrocodone-acetaminophen and lorazepam for one resident, oxycodone for another, and hydrocodone-acetaminophen for a third resident all reflected one more pill than was present in the blister packs. The discrepancies were identified during observation and record review, which revealed that the nurse responsible for administering the medications had not signed off on the Narcotic Administration Record log after giving the medications. The nurse admitted to administering the medications but forgetting to document the administration on the required logs. She acknowledged that she was aware of the requirement to sign both the narcotic count sheet and the Medication Administration Record after administration but failed to do so. Interviews with the Director of Nursing confirmed that staff are expected to document narcotic administration on both the MAR and the narcotic log, and that failure to do so could result in missing pills or overdoses. Additionally, when training records on narcotic administration were requested, none were provided. The facility's own policy required all controlled substances to be recorded on the designated usage form with clear and legible documentation, which was not followed in these instances.