Lack of Clear Indications for Controlled Pain Medications
Penalty
Summary
The facility failed to provide clear indications for the use of controlled pain medications for two of three sampled residents. For one resident admitted with cellulitis of the right leg, physician orders for oxycodone included dosage and pain level parameters but did not specify the indication for use. Medication administration records showed oxycodone was given for various types and locations of pain, including lower back pain, buttock pain, generalized pain, and instances where no pain location was documented. Another resident, admitted with a right femur fracture, had physician orders for hydrocodone-acetaminophen that also lacked a specific indication for use. Administration notes indicated the medication was given for leg pain, reported pain scores, and in some cases, without documentation of the pain location. Interviews with nursing staff and leadership confirmed that the orders were missing clear indications and that this information was necessary to prevent medication misuse. The facility's policy required that medication orders include the reason or problem for which the medication is given, but this was not followed in the cases reviewed. The lack of specific indications in the orders and inconsistent documentation of pain location led to the deficiency, as staff could not confirm the intended use of the controlled medications for the residents involved.