Failure to Accurately Document and Account for Narcotic Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate narcotic counts and documentation for two residents receiving pain management medications. Specifically, on one medication cart, the narcotic administration records for morphine sulfate and oxycodone did not match the actual pill counts in the blister packs for two residents. The nurse responsible for administering these medications admitted to giving the medications but failed to sign off on the Narcotic Administration Record log as required by facility policy. This lapse in documentation was confirmed during interviews, where the nurse acknowledged forgetting to sign and recognized the importance of this step. Further interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that both expected staff to document narcotic administration on both the Medication Administration Record (MAR) and the narcotic log, but neither could recall the last time they audited the medication carts. Additionally, when training records on narcotic administration were requested, none were provided. The facility's own policy required immediate documentation of controlled medication administration, including date, time, amount, and nurse's signature, which was not followed in these instances.