Inaccurate Documentation of Opioid Pain Medication Administration
Penalty
Summary
Surveyors identified a failure to ensure accurate documentation of opioid pain medication administration for two residents receiving hospice care. For one cognitively impaired, long-term care resident with diagnoses including Parkinsonism, anemia, dementia, psychosis, hypertension, and anxiety, the eMAR showed an order for Morphine Sulfate oral solution 20 mg/mL, 0.25 mg by mouth every eight hours for pain, and a separate PRN order for 0.25 mg every two hours as needed for pain. The eMAR reflected a 0.25 mg dose given at 5:00 A.M. under the scheduled every-eight-hours order, but review of the Controlled Drug Log showed that this same 5:00 A.M. dose was documented on the PRN morphine log page instead of the scheduled morphine log page. The DON confirmed that the entry was made on the incorrect Controlled Drug Log page. For another resident with diagnoses including cerebral infarction, Alzheimer's disease, atrial fibrillation, anxiety disorder, Type II diabetes mellitus, dysphagia, and unspecified convulsions, who was also on hospice and later expired in the facility, there were discrepancies between the Controlled Drug Log and the eMAR for PRN oxycodone administration. The resident had orders for Oxycodone HCl 5 mg by mouth twice daily for pain and Oxycodone HCl 5 mg every four hours PRN for pain. The Controlled Drug Log showed PRN oxycodone 5 mg doses administered on two separate dates at multiple times (including 8:00 P.M., 1:00 A.M., and 11:00 P.M.), but the corresponding PRN administrations were missing from the eMAR on those dates. The DON verified that the PRN oxycodone doses were documented on the Controlled Drug Log under the PRN order page but were not documented on the eMAR, contrary to the facility’s Medication Administration Policy requiring the individual administering the medication to electronically sign the eMAR after giving the medication.
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