Failure to Document Administration of Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure that narcotic pain medications administered to two residents were properly documented on the electronic medication administration record (EMAR). For both residents, the narcotic count sheets indicated that Oxycodone had been given on multiple occasions, but there were no corresponding signatures or documentation on the EMAR to confirm administration. Interviews with the residents revealed that they had not requested the as-needed narcotics on the dates in question, and one resident's family member confirmed a preference for non-narcotic pain relief. The lack of documentation was also confirmed during interviews with facility staff. The residents involved had significant medical histories, including dementia, chronic kidney disease, malignant melanoma, anxiety disorder, chronic lumbar degeneration, dysarthria following cerebral infarction, shoulder stiffness, type II diabetes with neuropathy, and major depressive disorder. Despite physician orders for as-needed Oxycodone, the absence of EMAR documentation for the administered doses constituted a failure to follow the facility's policy on the right documentation of medication administration.