Failure to Document Narcotic Administration on Medication Record
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of a prescribed narcotic pain medication. Specifically, for a resident diagnosed with fibromyalgia and prescribed oxycodone with acetaminophen to be given every four hours as needed for pain, the August controlled drug record showed multiple instances where the medication was administered. However, the corresponding MAR lacked documentation of these administrations on the listed dates and times. Interviews with staff confirmed that when as-needed pain medication is given, it should be documented both on the controlled drug record and the MAR. The facility's own policy, provided by the Director of Nursing, requires that all medications administered be immediately documented on the MAR, including the signature and title of the person administering the medication. The failure to document the administration of the narcotic medication on the MAR constituted a deficiency in maintaining accurate and complete medical records in accordance with professional standards.