Failure to Ensure Resident Remained Free from Significant Medication Errors
Penalty
Summary
A resident with diagnoses including end stage renal disease, opioid dependence, and chronic pain was not consistently administered the correct narcotic pain medication as ordered by the physician. The resident's care plan required medication to be provided per physician's orders to manage pain. However, review of medication administration records revealed that after an order for oxycodone-acetaminophen (Percocet) was initiated, the resident continued to receive oxycodone 5 mg tablets, for which there was no active order during that period. The records showed 28 administrations of oxycodone 5 mg without a valid order, while the ordered Percocet was not administered as prescribed. Additionally, when the order for oxycodone 5 mg was reinstated, the resident was inconsistently administered the medication as ordered, and there were instances where Percocet was given despite the absence of an active order for it. The facility's policy on controlled drugs required proper removal and destruction of discontinued medications, but the records indicated ongoing administration of discontinued medications. These actions resulted in the resident receiving incorrect narcotic medications on multiple occasions.