Failure to Document and Monitor Effectiveness of Controlled Substance Administration
Penalty
Summary
The facility failed to follow its medication administration policy and did not consistently monitor or document the effectiveness of pain medication for a resident receiving high alert medications. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse revealed that staff were not accurately documenting the administration of hydrocodone-acetaminophen in the Medication Administration Record (MAR) at the time of administration, as required by facility policy. The MAR and controlled substance sheets for the resident showed discrepancies, with the controlled substance being signed out twice daily but not always recorded in the MAR. The LPN acknowledged that documentation was not completed every time the medication was administered and could not provide a reason for the omission. Review of the resident's physician order sheet confirmed an order for hydrocodone-acetaminophen to be given every 12 hours as needed for pain, and the resident's care plan included interventions for pain management and monitoring effectiveness. However, there was no consistent documentation in the medical record indicating that nursing staff monitored the effectiveness of the pain medication as required. The facility's policy specified that the person administering medication must initial the MAR before administration and that late entries should be documented if missed, but these procedures were not followed in this case.