Incomplete and Inaccurate Documentation of Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medication administration records for a cognitively intact resident with multiple chronic conditions, including bladder cancer, diabetes mellitus, depression, chronic pain syndrome, and a right below-knee amputation. Facility policy on administering pain medications requires documentation of the pain assessment, medication, dose, route, and results of the medication in the resident’s medical record. The resident had an order for Oxycodone HCL 15 mg by mouth every 8 hours as needed for moderate to severe chronic pain, later changed to every 6 hours for a post-surgical period and then changed back to every 8 hours. Review of the February and early March 2026 MARs and the Individual Patient Controlled Substance Administration Record showed multiple discrepancies between doses documented on the controlled substance record and those recorded in the electronic medical record (EMR). On multiple dates in February and March 2026, doses of Oxycodone were recorded as administered on the Patient Controlled Substance Administration Record but were either missing or documented at different times in the EMR. Specifically, on several dates in February, one or more doses given at documented times (e.g., midnight, morning, afternoon, or late evening) on the controlled substance record were not recorded at all on the EMR MAR. On other dates, the times of administration differed between the two records, such as doses documented at 8:00 AM and 2:00 PM on the controlled substance record but at 9:11 AM and 3:00 PM in the EMR. Additional missing EMR entries occurred after the order reverted to every 8 hours, with several doses documented on the controlled substance record not appearing in the EMR. During an interview, the DON acknowledged that the EMR documentation was incomplete and did not reflect the controlled substance administration record, indicating noncompliance with the requirement to maintain clinical records in accordance with accepted professional standards.
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