Failure to Implement Physician's Orders for Pain Management
Penalty
Summary
The facility failed to implement a physician's order for a resident with diagnoses including spinal stenosis, heart failure, and diabetes. A physician's order dated December 4, 2024, required the administration of morphine ER twice daily. However, on December 5, 2024, it was documented that the pharmacy did not have morphine available. Subsequently, on December 9, 2024, the physician ordered oxycodone HCl ER as a temporary replacement, to be discontinued upon the arrival of morphine ER. The Medication Administration Record showed that the oxycodone HCl ER was not administered as ordered on December 9, 2024, at 9:00 p.m. Furthermore, when the morphine ER was received, the staff failed to discontinue the oxycodone HCl ER, resulting in the resident receiving both medications simultaneously. In an interview on December 20, 2024, the Administrator confirmed the failure to administer the pain medication on December 9, 2024, and acknowledged that the resident continued to receive both oxycodone HCl ER and morphine ER concurrently.
Plan Of Correction
1. The Oxycodone for Resident # 1 has been discontinued. 2. Physician orders are to be implemented and followed as ordered by the physicians for all residents. An audit of new narcotic orders for the last 2 weeks will be conducted to ensure that physician orders are in place and followed as ordered by the physician. 3. The licensed nurses will be re-educated on physician orders regarding narcotic medications. 4. A weekly audit of all new narcotic orders will be conducted for 4 weeks, then a biweekly audit of new narcotic orders for 8 random residents will be conducted for 2 months to ensure that physician orders are in place and followed as ordered by the physician. Results of the audits will be presented to the center's QAPI Committee for review and follow-up actions as recommended.