Inaccurate Documentation and Control of Narcotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration and control of Hydrocodone–Acetaminophen, a narcotic medication, for Resident #2 in accordance with professional standards. Resident #2 had a physician’s order for Hydrocodone–Acetaminophen 5–325 mg, one tablet every eight hours at scheduled times of 2:00 AM, 10:00 AM, and 6:00 PM. The pharmacy dispensed 43 tablets (one 30‑tablet card and one 13‑tablet card) on 9/26/2025, and the pharmacist stated this supply should have lasted until 11/4/2025 if given as ordered. The facility was unable to locate the medication monitoring/control record for the 30‑tablet card. The available monitoring/control record for the 13‑tablet card showed the resident ran out of the medication on 10/5/2025, with the last documented dose removed at 2:00 AM. On the 13‑tablet card’s monitoring/control record, Nurse #1 documented removing the first dose at an unclear date at 8:00 PM, which was not a scheduled administration time for the resident, and this removal did not match the September MAR, which showed Nurse #1 administering a dose at 2:00 AM on 9/26/2025 with no further doses documented by her that month. The same monitoring/control record showed Nurse #1 removing doses on 10/2/2025 at 8:00 PM and again at “060,” an unclear military time, both unscheduled times, with no documentation of a 2:00 AM removal on that date. In contrast, the October MAR documented that Nurse #1 administered Hydrocodone–Acetaminophen at 2:00 AM on 10/2/2025. During an interview, the DON stated she observed that Nurse #1 documented tablet removals at unscheduled times that were not reflected on the MAR, and that Nurse #1 could not recall whether the medication had been administered or explain the discrepancies. The DON acknowledged that documentation on the monitoring/control record should match the MAR for clear accounting of the narcotic medication.
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