Failure to Accurately Document Narcotic Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with chronic pain syndrome and fibromyalgia. The resident had a physician's order for oxycodone-acetaminophen 5-325 mg to be administered every six hours as needed for pain. On a specific date, the resident's individual narcotic record sheet indicated that the medication was administered at two separate times. However, the December Medication Administration Record (MAR) did not reflect documentation of the medication being given at either time. During interviews, one nurse confirmed she had signed the narcotic record sheet but had not documented the administration on the MAR, acknowledging this as an error. The other nurse involved was no longer employed and could not be reached for comment. Both the DON and the Administrator confirmed that facility policy requires narcotics to be documented on both the narcotic sheet and the MAR when administered.