Failure to Administer Oxycodone per Physician Orders
Penalty
Summary
The facility failed to ensure that oxycodone hydrochloride (HCl), a narcotic pain medication, was administered according to physician orders for a resident admitted with multiple fractures and trauma. The resident's care plan lacked information related to pain management, and provider orders specified maximum dosing and frequency for oxycodone HCl. However, medication administration records and progress notes showed that the resident received oxycodone HCl more frequently than every four hours and in greater quantities than the maximum four doses per day as ordered. There were also instances where the resident received both 5 mg and 10 mg doses close together, resulting in a total dose that was not prescribed. Interviews with staff revealed that the facility ran out of medications in the emergency kit due to failure to reorder, leading to medication errors when the drugs were not available for administration. Staff also acknowledged that the narcotic count book did not contain proper dosing instructions, and orders were not consistently transcribed or recorded as required. Discrepancies were noted between the number of doses administered according to the medication administration record and the narcotic count book, with staff unable to account for the differences. Further, the pharmacy confirmed that the administration of both 5 mg and 10 mg doses together was a medication error, and the most current prescription for oxycodone HCl was not being followed by the facility. The director of nursing was unaware of the new order and acknowledged that errors occurred when doses were given more frequently than ordered and that these errors were not reported to the provider. The facility's policy required drug orders to be recorded and reviewed, but this was not consistently done.