Failure to Maintain Complete and Accurate Documentation for Narcotic Pain Medication Refill
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record in accordance with professional standards for one resident receiving chronic pain management. The resident was admitted with diagnoses including osteoarthritis of the knee, spinal stenosis, abnormalities of gait, major depressive disorder, and anxiety, and had a comprehensive MDS showing a BIMS score of 15/15, indicating intact cognition, and frequent pain. The resident had an active order for Morphine Sulfate Oral Tablet Extended Release 15 mg to be given every 12 hours for moderate pain. In an interview, the resident reported that in August there was a time when the facility ran out of morphine, it was not refilled timely, and that oxycodone and Percocet were given as substitutes during the period when morphine was unavailable. Review of the August MAR showed multiple scheduled morphine doses on specific dates and times marked with chart codes "#9" (Other/See Nurse Notes) and "#5" (Hold/See Nurse Notes). However, corresponding progress notes for those dates did not consistently document the reasons for these codes or the actions taken. Progress notes that were present included a physician note on one date ordering a lidocaine patch after a report of left knee pain, and several EMAR notes on later dates indicating "awaiting pharmacy delivery," "waiting on pharmacy delivery," and "med [out of stock] awaiting order." There was no documented evidence in the medical record that the facility contacted the resident’s medical provider to request a refill for the morphine from the time the medication first became unavailable until two days later. Interviews and external documentation further highlighted gaps in charting. The contracted pharmacy provided a timeline showing that an electronic refill request was received, a fax was sent to the physician for a needed script, a script with missing information was received, clarification was requested from facility staff, and the correct script was eventually received and the medication delivered. An RN stated that nurses were responsible for monitoring narcotic counts, that narcotics required a written script rather than electronic re-ordering, and that all related actions should be documented. The RN confirmed entering a "#9" code for a missed morphine dose without a corresponding progress note and could not recall calling the physician, acknowledging that such a call and its documentation should have occurred. The DON reported that an LPN had verbally stated multiple attempts were made to reach the physician, but these efforts were not documented in the medical record, contrary to the facility’s policies requiring complete, accurate documentation of services and all communication with physicians and supervisory staff in the resident’s record.
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