Incomplete MAR Documentation for PRN Hydrocodone Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving PRN hydrocodone-acetaminophen for post–knee replacement pain. The resident, an older female with unilateral primary osteoarthritis of the left knee, aftercare following left knee joint replacement, and an anxiety disorder, had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain (4–10). Review of the Medication Administration Record (MAR) showed missing sign-out entries for this hydrocodone from 2/21/26 through 2/27/26, despite the resident’s report that she had not missed any doses and that staff consistently provided the medication when needed. The facility’s narcotic sign-out sheet for February 2026, however, contained dates, signatures, and pill counts for hydrocodone administration on those same dates. During interviews, the DON acknowledged that the MAR for this resident was blank for the relevant period and stated she did not know why, suggesting there might be an issue with the electronic tracking system or that staff were not properly “clicking out” the medication in the system. RN A reported that she worked with the resident on pain control every day she worked, assessed the resident’s pain each morning, and administered hydrocodone whenever the resident requested it in accordance with the physician’s order, documenting only on the narcotics sign-out log. Direct observation on 2/27/26 showed RN A assessing the resident’s pain at level 6, pulling and administering the correct hydrocodone dose, and signing the narcotics document, with no infection control issues noted. The facility’s policy on controlled medications required the licensed nurse to immediately enter the date, time, amount administered, and signature on the accountability record after administration, but the MAR entries for hydrocodone were not completed for the specified dates.
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