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F0697
D

Pain Medication Administered Outside Physician-Ordered Parameters

Palo Alto, California Survey Completed on 05-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed nurses administered Norco 5-325 mg, a medication prescribed for severe pain (pain level 7-10), to a resident who had been admitted for aftercare following joint replacement surgery. The physician's order specified that Norco should only be given for severe pain, but the medication was administered on multiple occasions when the resident's pain level was documented as less than 7. These administrations occurred on numerous dates throughout the month, as recorded in the resident's Medication Administration Record (MAR). The Director of Nursing (DON) confirmed upon review of the MAR that Norco was given to the resident when her pain level did not meet the threshold specified in the physician's order. The facility's job description for registered nurses requires compliance with professional standards and physician orders when administering medications. The failure to follow the prescribed pain management protocol resulted in the resident receiving pain medication inappropriately.

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