Failure to Follow Opioid Dosing Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adhering to physician orders regarding the administration of opioid pain medication. The resident, who had severe liver disease with ascites, was prescribed two tablets of oxycodone every four hours as needed for pain levels of eight to ten out of ten. However, medication administration records showed that staff repeatedly administered two tablets of oxycodone for pain levels below the prescribed threshold, including pain levels as low as three. Multiple staff members confirmed that they either did not assess the resident’s pain level accurately or administered the higher dose regardless of the actual pain score. Interviews with staff revealed that some did not consistently ask the resident for their pain level, instead recording or assuming higher pain scores to justify administering two tablets. One staff member admitted to mistakenly giving two tablets when only one should have been given, and another stated that the resident was clear in communicating pain but still received the higher dose on several occasions. The Director of Nursing confirmed that physician orders were not followed as required, resulting in the resident receiving more opioid medication than indicated by the order parameters.