Incomplete Medication Documentation for Pain Management
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents, as evidenced by discrepancies between the controlled medication utilization records and the medication administration records (MAR) for Morphine Sulfate. For one resident with diagnoses including anxiety, dementia, and atrial fibrillation, the pain management care plan required administration and documentation of analgesic medications as ordered, with monitoring and documentation of side effects and effectiveness every shift. However, a review of the resident's records revealed that 34 doses of Morphine Sulfate were signed out in November, but only 26 doses were documented as administered on the MAR. Several specific dates were identified where doses were not documented, and there was no corresponding nursing assessment of the medication's effectiveness in the progress notes. Similarly, for another resident with chronic pain, lumbar back pain, repeated falls, and muscle wasting, who was also receiving hospice services, the controlled medication utilization record showed 35 doses of Morphine Sulfate signed out over a specified period, but only 14 doses were documented as administered on the MAR. Multiple dates were identified where documentation was missing, and there was no evidence in the MAR or nursing progress notes of any assessment regarding the effectiveness of the administered medication. Interviews with nursing staff revealed a lack of awareness regarding the missing documentation for both residents. The staff nurse interviewed was not aware of the failure to sign off on administered doses and confirmed the existence of both standing and as-needed orders for Morphine Sulfate. The facility's pain management policy required collaboration with healthcare professionals and documentation of interventions, but the records reviewed did not reflect compliance with these requirements.