Failure to Accurately Document Narcotic Administration in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically regarding the administration of hydrocodone-acetaminophen for pain management. Record review revealed that the Medication Administration Record (MAR) did not match the narcotic sheet, which documented the removal and administration of the medication. The narcotic sheet and blister pack both indicated that a dose was given, but the MAR lacked documentation for the corresponding date and time. Interviews with facility staff, including the Administrator, ADON, and DON, confirmed that both the MAR and narcotic sheet are required to be consistent and accurately reflect when a narcotic is dispensed to ensure proper medication tracking and resident safety. The resident involved had multiple complex medical conditions, including diabetes, necrotizing fasciitis, stage 4 and unstageable pressure ulcers, and was receiving insulin and IV medications. The resident's care plan included chronic pain management with analgesic medications as ordered by the physician. Despite these needs, the facility did not ensure that the MAR was updated to reflect the actual administration times of the prescribed pain medication, as evidenced by the discrepancy on the narcotic sheet and MAR. Facility policy requires accurate documentation and investigation of any discrepancies, but this was not followed in this instance.