F0842

D

Incomplete Documentation of Controlled Pain Medication Administration

Silver Spring, Maryland Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records, specifically related to medication administration documentation for one resident. The facility’s Medication Administration policy instructs nursing staff to sign the Medication Administration Record (MAR) after administering medications and to sign the narcotic book for controlled substances; however, the policy itself lacked implementation and revision dates and did not identify who reviewed or revised it. During an interview, the DON stated that none of the facility’s policies and procedures had dates indicating when they were implemented. A physician’s order dated 02/04/26 directed staff to administer Oxycodone 5 mg orally every 6 hours as needed for left arm pain greater than 5/10 for 30 days.

Review of the resident’s controlled medication utilization record showed that nursing staff administered 18 doses of Oxycodone 5 mg between 02/05/26 and 03/09/26, while the February and March MARs reflected documentation of only 6 administered doses during that same period. For three of the documented doses, the MAR entries recorded pain scores of 3/10 and 0/10 at the time of administration. Further review revealed that on multiple specific dates and times, staff signed out Oxycodone on the controlled medication utilization record but failed to perform and document pain assessments and failed to initial the MAR to show administration of the 5 mg Oxycodone doses. This discrepancy between the controlled substance record and the MAR, along with missing pain assessments, demonstrated that the facility did not have an effective system to ensure complete and accurate clinical documentation for this resident’s medication administration.