Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of as needed (PRN) narcotic pain medication. Review of the clinical record for a resident with diagnoses including depression and pain showed that the physician had ordered Percocet (oxycodone-acetaminophen) 5-325 mg every 6 hours as needed for pain. Controlled substance records indicated that the medication was administered on multiple occasions across October and November, but the corresponding MARs for those months lacked documentation of these administrations. During interviews, an LPN confirmed that both the MAR and the controlled substance record should be signed when a narcotic is given, and facility policy required documentation of controlled substances in accordance with applicable law.