Failure to Administer Pain Medication per Ordered Parameters
Penalty
Summary
The facility failed to administer pain medication according to the ordered pain level parameters for two residents. For one resident with a history of cerebral infarction and osteomyelitis, the Licensed Vocational Nurse (LVN) administered hydrocodone-acetaminophen 5-325 mg for a reported pain level of 7/10, despite the current physician order specifying the medication should be given for moderate pain (4-6). The medication blister pack and reconciliation count sheet still reflected the previous order for severe pain (6-10), and the pharmacy had not received the updated order. Review of the Medication Administration Record (MAR) showed that this resident received the medication outside the ordered pain parameters on seven occasions. Interviews with nursing staff and the pharmacist confirmed that when medication orders are changed, the new parameters should be communicated to the pharmacy and reflected on the medication packaging. The staff acknowledged that it is their responsibility to ensure medications are administered according to the most current orders. The facility's policy requires medications to be administered in accordance with prescriber orders, including any specified parameters, but this was not followed in these instances.
Plan Of Correction
F-tag 760 I: Corrective Action for residents found to have been affected: Resident 21 is no longer in the facility as of 05/22/2025. • Resident 1 was reassessed by RN and duty on 05/18/2025 for any negative effects due to an incorrect hydrocodone-acetaminophen order. Resident remains stable at this time. • A one-on-one in-service education was provided to LVN 4 on 05/18/2025 by the DON regarding hydrocodone-acetaminophen administration within the pain level parameters per the physician order. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 06/06/2025, the DON conducted an audit to review residents on pain management to ensure residents are receiving pain medication based on pain level parameters as ordered by the physician. • No other residents have been affected by the deficient practice. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication as prescribed by the physician. • The Pharmacy Nurse consultant will conduct a 3-way medication cart audit on a monthly basis for the presence of medications and accuracy of orders. Findings will be reported to the DON for follow-up. • The Pharmacy Nurse consultant will continue monthly medication pass skills competency to licensed nurses. Any findings will be reported to the DON for follow-up. • The Medical Records Director/designee will conduct a daily audit for new physician orders for accuracy and will report findings to the DON during the daily stand-up meeting for follow-up. IV: Facility's plan to monitor corrective actions to achieve & sustain compliance; integrate the POC to QA process: • DON/designee will report issues or trends from the weekly random audits made on residents on pain management during the monthly QAA meeting for 3 months to ensure compliance. • The Pharmacy consultant will report issues or trends of monthly medication administration given by the pharmacy nurse consultant and monthly in-service educations provided regarding medication administration and review of residents on pain management. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025