Failure to Accurately Administer and Document Narcotic Pain Medication
Penalty
Summary
A deficiency occurred when a resident with chronic pain and diabetic polyneuropathy, who was alert and oriented, did not receive narcotic pain medication as ordered by the physician. The resident was prescribed oxycodone 5 mg to be administered three times daily for pain management. On a specific date, the Medication Administration Record (MAR) indicated that the 2:00 PM dose was signed off as administered by an LPN, but the Controlled Substance Disposition Record did not show that the medication was dispensed at that time. The disposition record only reflected administration at 6:00 AM and 10:00 PM. During interviews, the LPN could not recall the specific resident or event but stated that if the medication was not signed out on the disposition record, it was not administered, and she was unsure why it was marked as given on the MAR. The Director of Nursing confirmed that an audit of the records could not verify whether the 2:00 PM dose was actually given. Facility policy required staff to follow provider instructions and document medication administration accurately, which was not done in this instance.