C4975

Failure to Document Pain Medication Administration on MAR

Tarzana Health And Rehabilitation CenterTarzana, California Survey Completed on 03-12-2025

Summary

Licensed nurses at the facility failed to properly document the administration of pain medication for a patient with chronic pain syndrome. Specifically, on two occasions, Norco was removed from the medication cart and signed out on the Controlled Drug Record (CDR) for the patient, but there was no corresponding entry on the Medication Administration Record (MAR) to indicate that the medication was administered. The MAR is required to be signed after medication administration to ensure accurate documentation and assessment of the patient's pain and response to treatment.

During interviews, both the licensed nurse involved and the Director of Nursing confirmed that the established process requires signing the CDR, administering the medication, and then signing the MAR. The absence of documentation on the MAR meant that there was no record of the patient's pain assessment or the effectiveness of the pain medication for those times. Facility policy also requires the MAR to be signed after medication administration, and the CDR, in conjunction with the MAR, serves as the official record for controlled substance administration.

Plan Of Correction

C4975: T22 DIV5 CH3 ART5-72543(f)
Patients' Health Records

Corrective action for resident found to have been affected by this deficiency:
On 3/11/2025, DON provided 1:1 in-servicing to LVN 4 regarding proper PRN controlled medication administration documentation and accountability.

Identify any other residents who may have been affected by the deficient practice:
On 3/12/2025, MRD audited the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. There were no other issues identified.

Measures that will be put into place to ensure that this deficiency does not recur:
Beginning 3/11/2025, DSD initiated in-servicing for licensed nursing regarding proper documentation and signing for administration of controlled medications. (To continue)

Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur:
Beginning 3/12/2025, MRD will perform weekly audits of the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting.

Date of corrective action would be completed: 04/03/25

Penalty

No penalty information released