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F0757
D

Failure to Monitor for Oxycodone Side Effects

Ceres, California Survey Completed on 05-16-2025

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

A deficiency occurred when a resident with a diagnosis of chronic pain syndrome was administered oxycodone hydrochloride every eight hours for pain management without adequate monitoring for side effects. Review of the resident's Medication Administration Record and Progress Notes revealed no documentation of monitoring for potential adverse effects such as constipation, decreased respirations, dizziness, or increased fall risk. Interviews with both the Licensed Vocational Nurse and the Director of Nursing confirmed that staff were not documenting any monitoring of the resident for side effects related to oxycodone use. The facility's policy on pain assessment and management required monitoring for adverse consequences of pain treatment, and professional references also indicated the need for monitoring patients on oxycodone for side effects. Despite these requirements, there was no evidence that staff tracked or documented the resident's response to the medication or any adverse effects, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.

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