Failure to Administer Scheduled Narcotic Medication Timely and Document Appropriately
Penalty
Summary
A deficiency was identified when a resident on comfort care, with diagnoses including dementia, multiple sclerosis, and peripheral artery disease, did not receive prescribed narcotic pain medication (Morphine) according to the scheduled times. The medication was ordered to be administered three times daily at specific times, but review of the Medication Administration Records for April and May 2025 revealed multiple instances where doses were given outside the regulated window of one hour before or after the scheduled time. Additionally, there was no documented evidence that three scheduled doses were administered on certain dates, and no documentation was found indicating that the physician was notified of these omissions or late administrations. The facility's Medication Administration policy requires medications to be administered as prescribed and within the specified time frame, observing the six rights of medication administration. Despite this, the records showed that doses were frequently late, sometimes by several hours, and in some cases, not signed out on the narcotic log sheet. Interviews with nursing staff revealed that heavy medication passes and unfamiliarity with the facility contributed to the delays. Staff also indicated that when medications were administered late or omitted, they were supposed to notify a supervisor and document the event, but there was no evidence of such notifications or documentation in this case. Further interviews highlighted additional issues, such as the unavailability of Morphine in the facility at times, which led to delays in administration. Staff reported that when medications were unavailable, they would contact the pharmacy and notify the physician, but again, there was no documentation to support that these steps were taken for the missed or late doses. The lack of adherence to medication administration schedules and failure to document or communicate deviations from prescribed orders constituted the basis for the deficiency.