Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed by the physician for two out of four sampled residents. For one resident with diagnoses including metabolic encephalopathy and mood disorder, the physician's order specified that Oxycodone-Acetaminophen should be given only for breakthrough pain rated 4-10 out of 10. However, the Medication Administration Record (MAR) showed that the medication was administered when the resident's pain level was documented as 0 and 3, which did not meet the criteria outlined in the physician's order. Interviews with nursing staff confirmed that the medication was given outside the prescribed parameters, and staff acknowledged that this was not in accordance with the order. Another resident, admitted with diagnoses such as encephalopathy, sciatica, and dementia, had a physician's order for Hydrocodone-Acetaminophen to be administered for moderate to severe pain (pain level 4-10). The MAR indicated that this resident also received pain medication when their pain level was documented as 0. Staff interviews confirmed that the medication should not have been administered at a pain level of 0, and that the documentation was inaccurate. The facility's policy on administering medications requires that medications be given in accordance with prescriber orders, including any specified parameters. The observed practice of administering pain medication outside the prescribed pain levels for both residents was not consistent with these requirements, as confirmed by staff interviews and record reviews.