Failure to Follow Physician-Ordered Pain Parameters for PRN Medication
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident, as evidenced by the administration of Morphine Sulfate without following physician-ordered pain parameters. Specifically, the physician's orders required that Morphine Sulfate 30 mg be given by mouth every four hours as needed for pain rated at 7/10 or greater, and later for pain rated at 5/10 or greater. However, review of the resident's Medication Administration Record (MAR) for March and April revealed multiple instances where the medication was administered despite documentation of a pain level of 0, indicating no pain at the time of administration. Interview with the Unit Manager confirmed that the resident received the medication on these occasions with a documented pain level of 0. This failure to follow the seven rights of medication administration, specifically the right indication, resulted in the administration of a controlled substance without clinical justification as per the physician's orders.