Inaccurate MAR Documentation for Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate documentation on the Medication Administration Record (MAR) for a resident with a history of chronic pain syndrome and opioid dependence. The resident was prescribed methadone three times daily for pain management. Review of the MAR for October and November revealed that methadone was signed as administered on several occasions, but there was no corresponding Controlled Drug Record (narcotic sheet) to indicate the medication was available or actually given on those dates and times. Interviews with nursing staff confirmed that they had signed the MAR indicating administration of methadone when, in fact, the medication was not given, attributing the errors to accidental documentation. The resident also reported that there were multiple instances when the facility was unable to obtain methadone from the pharmacy. Facility policy required that medications be administered as prescribed and that staff document administration accurately, including signing the MAR only after giving the medication. The Director of Nursing and the Administrator both confirmed that signing the MAR for medications not administered results in inaccurate medical records. The deficiency was identified through record review, staff and resident interviews, and policy review, and was investigated under a specific complaint number.