Failure to Accurately Document PRN Opioid Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents who were prescribed as-needed Hydrocodone-Acetaminophen for severe pain. For both residents, the Controlled Drug Receipt Record/Disposition Form showed that an LPN signed out the medication, but there was no corresponding documentation on the Medication Administration Record (MAR) indicating that the medication was actually administered. The facility's guidelines require that the individual administering the medication must record the administration on the MAR immediately after giving the medication, including the date, time, dose, route, and their signature or initials. Both residents involved had complex medical histories, including chronic pain conditions and other significant diagnoses. Interviews with staff confirmed the process for signing out and documenting controlled substances, and the administrator acknowledged that the required documentation was missing from the MAR for both residents, despite the medication being signed out on the controlled drug record. This lack of documentation is not in accordance with the facility's own medication administration guidelines.