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F0684
D

Pain Medication Administered Outside Physician Orders

San Jose, California Survey Completed on 04-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed nurses administered hydrocodone-acetaminophen 5-325 mg to Resident 99 for pain levels of 7 and 5, despite physician orders specifying that this medication was to be given only for severe pain rated 8-10. Resident 99, who was admitted with polyneuropathy, had physician orders in place requiring pain level monitoring every shift and administration of hydrocodone-acetaminophen only for severe pain. Review of the Medication Administration Record confirmed that the medication was given for moderate pain levels, contrary to the physician's orders. The Director of Nursing confirmed that the nurses did not follow the prescribed protocol and should have notified the physician for pain levels less than 8, as per the facility's policy on pain assessment and management.

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