Failure to Accurately Document PRN Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when documentation of a PRN narcotic dose was inconsistent across required records. The resident, who had diagnoses including low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis, had an active physician order for oxycodone 5 mg by mouth every 4 hours as needed for pain until it was discontinued following the resident’s death. A nursing note signed by employee E3 at 3:09 a.m. documented that the resident exhibited signs and symptoms of pain and that one PRN dose of oxycodone was given with a positive effect. The narcotic reconciliation log showed that an oxycodone dose was signed out at 1:38 a.m. the same date. However, review of the MAR revealed that this oxycodone dose was not documented there. In an interview, the Nursing Home Administrator and the Director of Nursing confirmed that the oxycodone dose was not signed out on the MAR and that facility expectations require all narcotics to be documented both in the narcotics log and on the MAR.
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