Failure to Document Narcotic Administration on MARs
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three residents by not documenting the administration of controlled pain medications on the Medication Administration Record (MAR) as required by facility policy and professional standards. For each resident, staff administered medications such as tramadol and morphine, signed the narcotic sheet, but did not record the administration on the MAR. Interviews with the involved LVNs and SDC confirmed that they were responsible for this documentation and acknowledged the omission, often attributing it to being busy or distracted after signing the narcotic sheet. The residents involved had significant medical histories, including chronic pain, peripheral vascular disease, hemiplegia, heart failure, chronic kidney disease, diabetes, and vascular dementia. Despite having care plans and physician orders for pain management, the staff did not consistently document the administration of as-needed pain medications on the MAR, even though they had been trained on the importance of this process and the facility's policy required documentation in both the narcotic sheet and the MAR. The Director of Nursing (DON) confirmed that the staff did not follow facility policy, which mandates that all administered narcotics be documented in two places. The DON also verified that the MARs for the relevant dates were blank, indicating the medications were not recorded as given. Staff interviews revealed an understanding of the importance of proper documentation for resident safety and continuity of care, but the required documentation was still not completed at the time of the incidents.