Failure to Accurately Document PRN Controlled Medications on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident. The resident was re-admitted with multiple diagnoses, including acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention. An admission MDS showed moderate cognitive impairment. The resident’s care plan included a focus on pain management, with interventions such as administering analgesics per orders, anticipating pain needs, monitoring for non-verbal signs of pain, and using non-pharmacological interventions before PRN medications. Another care plan focus addressed behavior problems related to impaired cognition and impaired safety awareness, including verbal behaviors such as yelling out and banging on the table, with interventions to administer medications as ordered and monitor and document side effects and effectiveness. Physician orders dated January 2, 2026, included PRN Morphine Sulfate oral solution (20 mg/ml, 0.25 ml every 4 hours for pain/shortness of breath) and PRN Lorazepam Intensol oral concentrate (2 mg/ml, 1 ml every 2 hours for anxiety evidenced by restlessness/agitation). A behavior note on the same date documented that the resident continued to yell throughout the day, that redirection was ineffective, and that PRN doses of lorazepam and morphine were administered into the resident’s cheek pocket, pending effectiveness. The Individual Control Drug Records showed that two doses of morphine and two doses of lorazepam were administered on that date, at 10:00 a.m. and again at 12:10 p.m. Despite these entries on the narcotic control records and in the behavior note, the Medication Administration Record (MAR) for January 2026 contained no documentation that any doses of morphine sulfate oral solution or 2 mg/ml lorazepam were administered to the resident. The MAR also showed no recorded episodes of anxiety or restlessness for any shift in January 2026 under target symptoms/behavior tracking. Interviews with an RN, an LPN, and the DON confirmed that facility practice and policy require nurses to document all administered medications on the MAR, including date, time, dosage, route, symptoms, and results, and that controlled substances must also be recorded on narcotic reconciliation sheets. The DON reviewed the records and acknowledged that, although the narcotic sheets showed administration of morphine and lorazepam at 10:00 a.m. and 12:10 p.m., the MAR did not reflect these administrations, which did not meet the facility’s documentation expectations and policies.
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