Incomplete and Inaccurate Documentation of Narcotic Administration on MARs
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents by not consistently documenting the administration of narcotic medications on the medication administration record (MAR) and by documenting administrations that were not supported by the narcotic sign-out sheets. For one resident, a physician order dated 12/4/2025 directed Morphine Sulfate Oral Solution 100 mg/5 mL, 0.5 mL by mouth every 4 hours as needed for shortness of breath or discomfort. The December MAR showed only one dose given on 12/5/2025 at 9:33 a.m., while the narcotic sign-out sheet, which is not part of the clinical record, showed additional doses given on 12/4/2025 at 5:00 p.m. and 9:00 p.m. and on 12/5/2025 at 9:00 a.m., with only the 12/5/2025 9:00 a.m. dose reflected in the clinical record. For the same resident, a physician order dated 12/4/2025 for Lorazepam 0.5 mg, one tablet by mouth every 4 hours as needed for anxiety, restlessness, or agitation for 14 days, was present on the December MAR, but there was no documentation on the MAR that the medication had been administered, despite the narcotic sign-out sheet showing doses given on 12/4/2025 at 5:00 p.m. and 9:00 p.m. and on 12/5/2025 at 1:00 a.m. For a second resident, staff inconsistently documented Morphine and Lorazepam administrations between the MAR and the narcotic sign-out sheet. A physician order dated 12/4/2025 for Morphine Sulfate Solution 20 mg/mL, 0.5 mL by mouth every 2 hours for pain, was recorded on the December MAR with administrations documented on 12/4/2025 at 4:00 p.m., 8:00 p.m., and 10:00 p.m.; however, the narcotic sign-out sheet only showed a dose at 6:00 p.m. that day. Additional MAR entries on 12/5/2025 at 6:00 a.m. and on 12/6/2025 at 2:00 a.m. were not supported by corresponding entries on the narcotic sign-out sheet, and on 12/6/2025 at 6:00 a.m. the MAR indicated both that the resident was sleeping and that the dose was administered. For the same resident, a physician order dated 12/4/2025 for Lorazepam Oral Concentrate 2 mg/mL, 0.25 mL by mouth every 2 hours for anxiety, was documented on the December MAR. On 12/6/2025 at 2:00 a.m., the MAR showed administration of Lorazepam without a matching entry on the narcotic sign-out sheet, and at 6:00 a.m. the MAR documented the resident was sleeping and the medication was not given, while the narcotic sign-out sheet documented that the dose was administered. An LPN stated that the process for administering a narcotic is to remove it from the narcotic box, sign it out in the narcotic book, and then document the dose on the MAR.
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