F0658

E

Clustered False Documentation and Non-Individualized PRN Opioid Administration

Eupora, Mississippi Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure licensed nursing staff followed professional standards of practice for accurate, individualized assessment and documentation of PRN opioid pain medications for 13 residents on one medication cart. Facility policies required medications to be administered as prescribed, in accordance with good nursing principles, and clinical records to be complete and accurate for continuity of care, including consistent evaluation, management, and documentation of pain. Despite these requirements, record review of January and February 2026 MARs and controlled substance records showed repetitive, clustered documentation of PRN narcotic administration at identical times for multiple residents, which did not reflect individualized assessment or real-time documentation. One resident reported concerns that an LPN attempted to administer medications without allowing her to visually verify them, that she questioned whether her Norco was present, and that she did not experience expected pain relief; on one occasion she observed a pill that did not resemble her usual Norco and was told it was broken.

Resident #9 was a cognitively intact resident with hemiplegia and hemiparesis following cerebral infarction, whose MDS indicated frequent pain affecting sleep and daily activities. However, during interviews he consistently denied pain, stated he did not take pain medication, and reported refusing pain medication when offered. Other LPNs confirmed that he did not usually take pain medication and had never reported pain or requested PRN analgesics from them. In contrast, MARs and the controlled substance inventory showed that one LPN (LPN #3) documented Norco administration to this resident at highly consistent times (around 7:01 AM, 12:31 PM, and 6:31–6:49 PM) and recorded pain scores of 8–9 on her shifts, while other shifts documented pain scores of zero. LPN #3 later admitted she did not ask this resident about pain, administered medication without his consent, and falsely documented high pain scores.

Across all 13 residents with PRN opioid orders (primarily Norco and one resident with oxycodone), MAR review revealed a pattern of clustered documentation by LPN #3, with large groups of residents recorded as receiving PRN pain medication at the exact same times on multiple dates. In January and February, PRN doses were repeatedly documented at standardized times such as 7:01 AM, 11:01 AM, 12:31 PM, 3:01 PM, and clustered evening times between 6:31 PM and 6:49 PM, sometimes for as many as 12 residents at once. LPN #3 acknowledged in a telephone interview that she administered all PRN pain medications during routine med passes and intentionally selected one set time for all residents so they could receive subsequent doses based on order frequency, and that the medical records did not accurately reflect actual administration times. She further admitted she did not always ask residents about their pain, sometimes entered pain levels without asking them, and recognized that this practice and her documentation were not in accordance with nursing standards. The DON confirmed that review of the 13 residents’ MARs showed a pattern of documentation inconsistencies related to this nurse, and the nurse had a history of prior medication documentation and narcotic handling issues identified through progressive discipline and consultant pharmacist review.