F0842

E

Inaccurate and Incomplete Documentation of Controlled Substances on MARs and Narcotic Records

Glasgow, Kentucky Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically related to documentation of controlled substance administration on Medication Administration Records (MARs) and Accountability Records (ARs)/Controlled Substance Inventory Records (CSIRs). Facility pharmacy policies required that the individual administering a medication immediately document the dose on the MAR after administration and, for controlled substances, also record the date and time, amount administered, remaining quantity, and initials on the AR, completed after the medication was actually given. Pharmacy audits and record reviews showed repeated discrepancies where narcotic doses were signed out or removed on ARs/CSIRs but not documented as administered on the corresponding MARs, and in one case, MAR documentation of narcotic administration was inconsistent with a negative urine opiate screen.

For one resident with Alzheimer’s disease, dementia, and Parkinson’s disease who was cognitively intact per a BIMS score of 14, the pharmacy’s PRN controlled substance audits showed multiple dates on which Norco 5-325 mg doses were documented as removed on the AR, but there was no corresponding documentation of administration on the MAR. These undocumented MAR entries occurred on several consecutive days, indicating that either the administration was not recorded as required or the medication was removed without proper MAR documentation. Another resident with osteomyelitis, Alzheimer’s disease, and dementia, assessed with severe cognitive impairment (BIMS score of 5), had numerous hydrocodone-APAP 5-325 mg doses documented as removed on the AR across multiple dates, yet none of these doses were documented on the corresponding MAR.

A third resident admitted with a right femur fracture and additional diagnoses including dementia, hypertension, and anxiety disorder, and assessed with severe cognitive impairment (BIMS score of 6), had MAR entries showing oxycodone-acetaminophen 5-325 mg administered twice daily over several days. However, a urine opiate screen obtained during that period was negative, with a normal reference range of negative, indicating the resident had not received the narcotic pain medication as documented on the MAR for those days. For another resident with mild dementia, a displaced left femur fracture, Type 2 diabetes, and chronic pain, the CSIR for oxycodone 5 mg showed four doses removed during a specified period that were not documented as administered on the MAR. Additional review showed doses removed from stock that were documented on the MAR only later, sometimes hours after removal, and some removed doses were never documented as administered on the MAR.

For a fifth resident with an unspecified displaced fracture of the right humerus, unspecified dementia, and hypertensive chronic kidney disease, and who was cognitively intact with a BIMS score of 14, the pharmacy’s PRN controlled substance audit showed multiple Norco 5 mg doses documented as removed on the AR on different dates without corresponding documentation on the MAR. Staff interviews confirmed that facility practice and expectation were that narcotic medications must be signed out on both the narc sheet (AR) and the MAR, and that discrepancies in narcotic counts should be reported to the ADON or DON. The pharmacist reported that PRN and periodic audits comparing narcotic sign-outs to MAR documentation revealed poor documentation, and that these concerns had been shared with the DON. The staff educator was unsure whether anyone specifically educated new hires on MAR documentation or whether chart audits were performed, and the DON acknowledged being made aware of documentation concerns by the pharmacist but stated she had not seen inconsistencies and that the pharmacist’s concerns were not brought to the QAPI committee. The administrator stated she was unaware of the pharmacist’s concern and would have considered inconsistencies between AR and MAR to be medication errors.