Failure to Monitor for Adverse Reactions to High-Risk Opioid Medication
Penalty
Summary
The facility failed to ensure that monitoring interventions for adverse reactions to a high-risk medication, specifically oxycodone, were implemented for one resident. The resident, who had a diagnosis of spinal stenosis and moderate cognitive impairment as indicated by a BIMS score of 8 out of 15, had an order for oxycodone HCl 5 mg, to be administered as half a tablet by mouth once daily. Upon review of the resident's medical record, it was found that there were no documented monitoring interventions for adverse reactions to the opioid medication, despite facility policy and current guidance requiring routine monitoring for side effects associated with high-risk medications such as opioids. The Director of Nursing (DON) confirmed during an interview that monitoring interventions for high-risk medications should be entered on the Medication Administration Record (MAR) when the medication order is transcribed. However, the DON acknowledged that the monitoring interventions were not re-entered into the resident's medical record when the oxycodone order was previously discontinued and then restarted. As a result, the resident's drug regimen was not adequately monitored for potential adverse reactions to the opioid medication.