Incomplete Documentation of Medication Administration Records
Penalty
Summary
The facility failed to ensure complete documentation of Medication Administration Records (MAR) for two residents. For one resident with end stage renal disease, heart failure, and type 2 diabetes, there were instances where Oxycodone was signed out on the narcotic record but not documented on the MAR as administered. Specifically, on two occasions, the narcotic was signed out but there was no evidence in the MAR that the medication was given. The Director of Nursing confirmed the absence of documentation in the MAR for these instances. For another resident with chronic kidney failure, cerebral infarction, and heart failure, multiple instances were identified where Oxycodone was signed out on the narcotic record but not documented on the MAR. The resident was cognitively intact and reported adequate pain management. The Director of Nursing also confirmed the lack of documentation in the MAR for these occasions. Additionally, although the Director of Nursing is responsible for periodic, randomized checks to ensure proper medication administration, there was no documented evidence that these checks were performed.