The documentation failure at Roosevelt Rehabilitation and Healthcare Center involved a resident with end-stage renal disease, chronic pancreatitis, low back pain and osteoarthritis who died in the facility after receiving the pain medication. Staff signed the oxycodone out of the narcotic reconciliation log but left the medication administration record blank.
Federal inspectors reviewed 12 resident medical records and found the documentation violation affected one patient. The resident had an active physician's order for OxyCODONE HCl Capsule 5 MG, one capsule by mouth every four hours as needed for pain.
Employee E3 wrote a nursing note at 3:09 a.m. documenting "signs and symptoms of pain" and noting that "x1 prn med oxycodone given" with "positive result." The narcotic reconciliation log showed an oxycodone signed out at 1:38 a.m. that same day.
But the medication administration record contained no signature for the dose.
The Nursing Home Administrator and Director of Nursing confirmed during a January 29 interview that no oxycodone dose was documented in the medication administration record. Both administrators acknowledged the facility expects all narcotics to be signed out in both the narcotic log and the MAR.
The resident's physician order for oxycodone remained active until it was discontinued following the patient's death.
Federal regulations require nursing homes to maintain complete and accurate medical records for each resident in accordance with accepted professional standards. The documentation failure represents a violation of safeguarding resident-identifiable information requirements.
The inspection was conducted in response to a complaint. Inspectors classified the violation as minimal harm or potential for actual harm affecting few residents.
Roosevelt Rehabilitation's failure to maintain dual documentation of narcotic administration creates gaps in medication tracking that federal regulators use to monitor controlled substance distribution in nursing facilities. The narcotic reconciliation log and medication administration record serve as cross-checks to ensure proper handling of controlled substances.
The facility's own policy requires staff to document narcotic administration in both records, according to statements from the administrator and nursing director. The violation occurred despite established protocols designed to prevent documentation gaps.
The resident died in the facility after receiving the inadequately documented oxycodone dose. The timing of the medication administration, occurring in the early morning hours when staffing is typically reduced, highlights vulnerabilities in narcotic tracking during overnight shifts.
Employee E3's nursing note provided clinical justification for the oxycodone administration, documenting observable signs and symptoms of pain and noting positive results from the medication. However, the failure to complete the medication administration record left an incomplete audit trail for the controlled substance.
The documentation gap occurred during the resident's final period of care, when pain management would be particularly critical for someone with multiple painful conditions including chronic pancreatitis and osteoarthritis. The resident's end-stage renal disease would have complicated pain management decisions.
Federal inspectors found the violation during a targeted review of clinical records following a complaint to the facility. The complaint investigation focused on medical record maintenance and identified the narcotic documentation failure as the primary deficiency.
Roosevelt Rehabilitation's administrator and nursing director both confirmed awareness of the facility's dual documentation requirements for controlled substances during their joint interview with inspectors. Their acknowledgment of the policy violation indicates the failure represented a breakdown in established procedures rather than unclear expectations.
The violation affects federal oversight of controlled substance distribution in nursing facilities. Incomplete narcotic documentation hampers regulators' ability to track medication administration patterns and identify potential diversion or inappropriate use of controlled substances.
The facility must correct the deficiency to maintain program participation in federal healthcare programs. Nursing homes cited for deficiencies must submit approved correction plans within required timeframes to continue receiving Medicare and Medicaid reimbursements.
The inspection findings become publicly available 14 days after documents are provided to the facility. Roosevelt Rehabilitation's violation joins thousands of nursing home deficiencies disclosed annually through the federal inspection process.
The resident's complex medical conditions, including end-stage renal disease and chronic pancreatitis, would have required careful pain management coordination between nursing staff and physicians. Proper documentation ensures continuity of care and regulatory compliance during such critical treatment periods.
Employee E3's detailed nursing note describing the resident's pain symptoms and medication response demonstrates clinical awareness of the patient's condition. The failure occurred in the administrative documentation rather than clinical assessment or treatment delivery.
The early morning timing of the medication administration highlights challenges nursing facilities face maintaining accurate records during overnight shifts when administrative oversight may be reduced. The 1:38 a.m. narcotic sign-out and 3:09 a.m. nursing note span a period when fewer supervisory staff typically monitor documentation compliance.
Roosevelt Rehabilitation's violation represents the type of administrative failure that federal regulators target through complaint investigations and routine inspections. The facility's acknowledgment of its own policy requirements indicates the documentation gap was preventable through existing procedures.
The resident died after receiving the inadequately documented oxycodone, leaving an incomplete record of controlled substance administration during the final period of care. The documentation failure affects both regulatory compliance and the medical record's completeness for the deceased resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roosevelt Rehabilitation and Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
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