Failure to Accurately Document PRN Pain Medication on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident who had dementia with moderate cognitive impairment, type 2 diabetes mellitus, and acute pain due to trauma. The resident’s care plan identified a risk for discomfort or pain related to immobility, with an intervention to administer pain medication as recommended by the physician. A physician’s order was in place for PRN acetaminophen 650 mg by mouth every 6 hours as needed for pain, not to exceed 3000 mg in 24 hours. Nursing documentation on the same day indicated that the resident complained of back pain after a fall and was provided PRN acetaminophen. However, review of the resident’s August medication administration record (MAR) showed that the PRN acetaminophen order was entered with a start time but had no nurse signature or indication that the medication was administered, despite the nurse’s progress note stating it had been given. During interview, the LVN acknowledged that if she administered the medication, she was responsible for documenting it on the MAR and stated she probably forgot to click it as administered. She confirmed she had been trained on medication administration documentation and understood that failure to document could affect subsequent nurses’ knowledge of prior doses. The DON confirmed that the medication should have been signed off on the MAR, that LVN A was responsible for the documentation, and that the MAR did not reflect administration. Review of the facility’s medication administration policy showed no specific language regarding documentation of administered medications in the MAR.
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