Failure to Review and Renew Pain Medication Orders
Penalty
Summary
A medical provider failed to appropriately review and manage pain medication orders for a resident with chronic pain due to trauma. The resident was admitted with an order for Oxycodone 15 mg every 4 hours as needed for pain, which was subsequently reduced in dosage and frequency by the nurse practitioner responsible for pain management. The Oxycodone order was eventually set to expire after 21 days, and upon expiration, the medication was discontinued without a documented review or renewal by the provider. The resident had not received the as-needed Oxycodone for a period following the discontinuation, despite ongoing reports of pain. The nurse practitioner acknowledged during interview that the 21-day limitation on the Oxycodone order was an error and that the medication should have been ordered indefinitely until a formal reevaluation occurred. The DON confirmed that the provider did not review the resident's medication orders at the time the Oxycodone order expired. The resident later reported that the discontinued as-needed medication had been effective in controlling pain, which was no longer managed after the discontinuation until the order was eventually reinstated.