Failure to Accurately Document and Administer Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident. Specifically, there was a discrepancy between the physician's orders for Acetaminophen with Codeine and the documentation on the resident's Electronic Medication Administration Record (EMAR) and Narcotic Count Sheet. The physician's orders were updated to allow for 2 tablets every 6 hours as needed for pain, but the Narcotic Count Sheet indicated that only 1 tablet was pulled and administered on several occasions, while the EMAR reflected administration of 2 tablets. Interviews with staff confirmed that only nurses were to administer and document narcotic medications, and that procedures required immediate and accurate documentation on both the EMAR and Narcotic Count Sheet. However, inconsistencies in documentation and administration were identified, with staff unable to explain the discrepancies. The resident involved had a history of Systemic Lupus Erythematosus and was cognitively intact, with a care plan addressing the need for pain management. The resident reported receiving 1-2 tablets at different times and was unaware of the reason for the variation. Staff interviews revealed that nurses were trained to perform medication checks and document administration, but there was uncertainty regarding the monitoring frequency of narcotic counts by the DON. Facility policy required immediate documentation of controlled medication administration, but this was not consistently followed, leading to inaccurate records for the resident's pain medication.