F0755

E

Inconsistent Documentation of Controlled Pain Medication Administration

Seneca, Missouri Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate and consistent documentation of the administration of controlled pain medications on both the Medication Administration Record (MAR) and the Controlled Substance Record for multiple residents. Facility policy dated 06/01/18 required that medications classified as controlled substances be subject to special handling, storage, disposal, and recordkeeping, and that current controlled substance accountability records be kept in the MAR or designated book. The policy also stated that the medication regimens of residents with discrepancies should be reviewed to assure residents received all medications ordered and that therapeutic goals were met. Despite this, surveyors identified numerous instances where documentation on the MAR did not match the Controlled Substance Record for three residents receiving opioid analgesics.

For one resident with chronic back and leg pain related to diabetic neuropathy, cervical disc degeneration, gout, and restless legs syndrome, the physician ordered hydrocodone-acetaminophen both as a scheduled and PRN medication. Review of this resident’s records showed repeated mismatches between the Controlled Substance Record and the MAR. On multiple dates in January and February, staff documented administration of hydrocodone-acetaminophen on the Controlled Substance Record without corresponding entries on the MAR, and on other occasions documented administration on the MAR without corresponding entries on the Controlled Substance Record. Some entries on the Controlled Substance Record included notes that the resident was out of the building, yet the MAR did not reflect administration at those times. There were also instances where times were missing or unreadable on the Controlled Substance Record while the MAR showed administration, further demonstrating inconsistent documentation.

A second resident with major depressive disorder, difficulty in walking, and muscle weakness had an order for PRN oxycodone 5 mg for moderate to severe pain. For this resident, the Controlled Substance Record repeatedly showed documented administrations of oxycodone on numerous dates across January, February, and March, while the MAR lacked corresponding entries for those same administrations. Each listed date and time on the Controlled Substance Record had no matching documentation on the MAR, indicating a pattern of incomplete or absent MAR documentation despite recorded use of the controlled medication.

A third resident with cognitive communication deficit, muscle weakness, chronic kidney disease, and a care plan requiring routine pain management for lower back pain had an order for PRN hydrocodone-acetaminophen. For this resident, the Controlled Substance Record documented multiple administrations of hydrocodone-acetaminophen on various dates in February and March, but the MAR did not show corresponding entries for those administrations. On each of the cited dates and times, staff signed out the narcotic on the Controlled Substance Record, yet there was no MAR documentation to match. During interviews, certified medication technicians and registered nurses stated that staff were expected to document pain medications on both the MAR and the controlled drug form, and that the two records should match. The administrator also stated she expected staff to document on the MAR and narcotic sheet and acknowledged that failure to sign the MAR made it easy to forget, characterizing the issue as a documentation problem.