Failure to Follow Professional Standards in Medication Administration and Weight Monitoring
Penalty
Summary
The provider failed to ensure that professional standards were met in the administration of PRN controlled pain medications for two residents. For both residents, the medication administration records showed that oxycodone was given at intervals shorter than the four hours specified in the physician's orders. In several instances, doses were administered less than one, two, or three hours apart, contrary to the prescribed schedule. Interviews with the director of nursing revealed uncertainty about the facility's policy regarding early administration of PRN medications, and a review of the facility's policy confirmed that medications were to be administered according to prescriber orders and the six rights of medication administration. Additionally, the provider did not follow professional standards in monitoring and responding to significant weight changes for a resident with congestive heart failure and a recent hip replacement. The resident experienced a documented weight gain of twelve pounds over two days, but there was no evidence that the resident was re-weighed to confirm the accuracy of the measurements, nor was there documentation that the charge nurse acknowledged the weight gain or that the physician was notified, as required by facility policy. Interviews with facility leadership confirmed that the policy was not followed in this instance.