Failure to Clarify Duplicate PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs by allowing duplicate pain medication therapy without clear parameters for administration. A resident with multiple diagnoses, including dementia, fibromyalgia, and chronic pain syndrome, was readmitted with physician orders for acetaminophen, hydrocodone-acetaminophen, and tramadol, all prescribed as needed for pain but without specific instructions or parameters to guide their use. The consulting pharmacist recommended updating the hydrocodone and tramadol orders to include clear instructions based on the pain scale, but the physician declined to make changes. The Director of Nursing acknowledged that the orders for these medications were not clear and required more specific instructions.