Failure to Document Narcotic Administration in MAR
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic medication administration for one resident, as required by their policies and procedures. Specifically, multiple doses of Hydrocodone-Acetaminophen administered to a resident were recorded on the narcotic count sheet but were not documented in the electronic Medication Administration Record (MAR) on several occasions. This discrepancy was identified through review of the narcotic count sheet and the MAR, which showed missing entries for the administration of the medication on specific dates and times. Interviews with staff involved in the administration of these medications revealed that the omissions were due to distractions, high workload, and failure to follow the established process of documenting in both the MAR and the narcotic count sheet. The DON, who administered one of the doses, acknowledged forgetting to document in the MAR after being pulled away to assist another resident. Similarly, two LVNs admitted to administering the medication and signing the narcotic count sheet but failing to document in the MAR due to being busy, distracted, or overwhelmed by their workload. The resident involved had multiple significant diagnoses, including acute respiratory failure, COPD, atrial fibrillation, congestive heart failure, and hypertension, and was assessed as having no cognitive impairment. The facility's policy required that all medication administrations be documented in the MAR and, for controlled substances, also on the narcotic count sheet. The failure to document in the MAR was confirmed by staff interviews and review of facility policy.