Failure to Accurately Dispense and Document Pain Medication Administration
Penalty
Summary
The facility failed to ensure accurate dispensing and administration of medications for a resident receiving comfort care for pain management. A physician's verbal order was given to administer 5 ml of Morphine every 3 hours and to discontinue all other medications. However, review of the narcotic count sheet revealed that nursing staff were administering only 0.25 ml per dose from the morphine solution, rather than the ordered 5 ml. This incorrect dosing occurred 22 times over a period of several days, involving multiple nurses. Additionally, documentation discrepancies were identified, as there was no evidence in the electronic medication administration record (eMAR) that the medication was administered on 5 out of the 22 occasions when it was pulled from the stock solution. All five undocumented administrations were recorded by an agency LPN. The Director of Nursing confirmed the lack of documentation for these administrations after reviewing the records and acknowledged the concern regarding the facility's failure to ensure accurate medication dispensing and administration.