Pain Medication Administered Outside Prescribed Indication
Penalty
Summary
The facility failed to ensure that pain medication was administered as prescribed for a resident with diagnoses including heart failure, metastatic prostate cancer, and muscle weakness. The physician's order specified that Oxycodone 5 mg immediate release should be given by mouth every four hours as needed for lower back pain. However, review of the medication administration record revealed that the medication was given on ten occasions for indications other than lower back pain, such as generalized pain, body pain, facial pain, and neck pain. Multiple nurses administered the medication for these unapproved indications without obtaining a new physician order to cover the broader pain complaints. Interviews with nursing staff confirmed that the medication was not administered strictly according to the prescriber's order, and the Director of Nursing acknowledged that a physician order should have been obtained for the resident's general pain. Although the physician and pharmacist later stated it was acceptable to administer the medication for other pain indications, the facility's policy required medications to be administered only as ordered by the prescriber. This deviation from the prescribed order resulted in a failure to provide safe and appropriate pain management as required by facility policy.