Unjustified Duplicate Opioid Therapy for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the use of duplicate opioid pain medications. Resident 28, who was admitted with diagnoses including dementia and polyneuropathy, was prescribed multiple opioid and non-opioid pain medications. These included Morphine Sulfate Solution, Fentanyl transdermal patch, Gabapentin, and Oxycodone HCL. The clinical record review did not provide documentation justifying the use of these duplicate opioid medications for the resident. During an interview, the Director of Nursing confirmed the absence of justification for the duplicate pain medication therapy for Resident 28. The resident's quarterly Minimum Data Set assessment indicated moderate cognitive impairment and frequent severe pain, necessitating staff assistance for daily activities. Despite these conditions, the lack of documented justification for the concurrent use of multiple opioid medications constituted a deficiency in the resident's care.
Plan Of Correction
Resident 28 was discharged from the facility. An audit of current residents receiving duplicate opioid pain medication will be completed to ensure documented justification. An education to the licensed nursing staff and the attending physicians will be completed regarding unnecessary medications. Monthly audits will be conducted by the DON/designee for 3 months for residents on duplicate pain medication to ensure documented justification. Results of the audits will be reviewed at monthly QAPI x 3 months.