Incomplete and Inconsistent Documentation of Opioid Administration Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medication administration records (MARs) and controlled substance records for residents receiving opioid medications. For a resident with Alzheimer’s dementia, failure to thrive, and abnormal weight loss, a physician ordered Morphine Sulfate Concentrate 100 mg/5 ml, 0.25 ml by mouth every 2 hours as needed for pain or shortness of breath. In December, the MAR showed Morphine administrations on specific dates and times that were not reflected on the controlled substance record, and the controlled substance record showed additional administrations that were not documented on the MAR. Specifically, on one date the MAR showed doses at 10:00 a.m. and 12:00 p.m. that were not recorded on the controlled substance record, and on another date the MAR showed an 8:00 a.m. dose while the controlled substance record showed doses at 8:00 a.m., 10:00 a.m., and 9:49 p.m., with no corresponding MAR entries for the latter two times. A second resident with bladder cancer had a physician order for Oxycodone Oral Concentrate 100 mg/5 ml, 1 ml by mouth every 4 hours as needed for breakthrough pain. In November, multiple discrepancies were identified between the MAR and the controlled substance record for this medication. On several dates, the controlled substance record showed Oxycodone doses administered at various times that were not documented on the MAR, and on other dates the MAR showed doses that were not reflected on the controlled substance record. During an interview, an LPN stated that whenever a controlled medication such as an opioid is administered, it must be signed out on the controlled substance record and documented on the MAR, and that if a medication is not initialed on the MAR, it would mean the medication had not been given. The facility’s policy on managing controlled substances required timely documentation of administrations on both the descending count sheet and the MAR for each routine and as-needed dose, which was not followed in these instances.
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