Failure to Follow Physician Orders for PRN Pain Medication Administration
Penalty
Summary
Facility staff failed to administer as needed (PRN) pain medication according to the physician's orders for a resident with diagnoses including muscle weakness, low back pain, and neuropathy. The care plan required that oxycodone be given only for severe pain rated seven through ten, and that at least two nonpharmacological interventions be attempted before administering the medication. However, review of the Medication Administration Records (MAR) for May and June 2025 showed that staff administered oxycodone when the resident's pain level was less than seven on multiple occasions, and there was no evidence that nonpharmacological interventions were attempted prior to medication administration on most occasions in June. These findings were confirmed by staff interview.