Failure to Accurately and Timely Document Controlled and Routine Medications
Penalty
Summary
Surveyors identified a failure to maintain accurate and timely medication records for controlled substances and other medications, including discrepancies between the EMAR and the facility’s narcotic log, and failure to document medications at the time of administration. One resident with arthritis and chronic pain had a PRN tramadol 50 mg order for moderate to severe pain every eight hours; the EMAR showed multiple administrations during the month, while the narcotic log for the same period showed additional tramadol doses that were not documented on the EMAR. Another resident with leukemia and chronic pain had orders for scheduled oxycodone 5 mg twice daily and PRN oxycodone 5 mg every 24 hours; the EMAR for the review period showed no PRN oxycodone administrations, but the paper narcotic log showed an oxycodone dose signed out at a time that did not correspond to the scheduled AM or PM medication passes and was not documented as PRN on the EMAR. In both cases, the DON confirmed that controlled substances should be documented on both the EMAR and the narcotic log. Surveyors also observed a failure to document routine medications at the time of administration for another resident admitted with multiple diagnoses including peripheral vascular disease, partial foot amputation, stroke, liver disease, and chronic kidney disease. This resident had orders for amlodipine 10 mg daily, apixaban 2.5 mg daily, metoprolol 25 mg twice daily, and pantoprazole 40 mg daily. During a medication pass, an LPN administered these medications but did not sign them as given in the EMAR at the time of administration. More than two hours later, the EMAR still did not show documentation of the morning medications, and the LPN was observed sitting at the nurse’s station talking with coworkers rather than charting. The LPN verified that the medications administered earlier remained undocumented. Facility policy required staff to document administration of controlled substances in accordance with law, document when medications are given, and document PRN medications on appropriate forms.
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