Failure to Accurately Document and Reconcile Narcotic Medication Orders and Administration
Penalty
Summary
The facility failed to ensure accurate and consistent documentation and administration of a physician-ordered narcotic medication for one resident. Specifically, the physician's order for oxycodone was not accurately reflected on both the narcotic sheet and the Medication Administration Record (MAR). The narcotic record showed a different dosage and frequency than the physician's order and the MAR, and the number of tablets received from the pharmacy was altered on the narcotic record without proper documentation. Additionally, the MAR did not show administration of the medication on certain dates, even though the narcotic record indicated it had been given. Nursing staff did not consistently document the administration of narcotic medications on the MAR as required by facility policy. On several occasions, the nurse signed out the medication on the narcotic sheet but failed to document it on the MAR. There were also instances where the quantity of medication administered was altered on the narcotic sheet without explanation, and the required information on the medication count sheets, such as nurse initials and verification, was left blank. The orders on the narcotic sheet, MAR, and physician's order sheet did not match, and discrepancies were not promptly identified or corrected. The resident involved had multiple complex medical conditions, including chronic pain, kidney failure, heart disease, and was receiving hospice services. Despite the facility's policies outlining the steps for safe administration and documentation of oral and narcotic medications, these procedures were not followed. Staff interviews confirmed that the expected protocols were not adhered to, and the errors in documentation and order reconciliation were only discovered during an audit.