Failure to Notify Physician and IDT of Medication Administration Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that physician orders were followed regarding the administration of pain medication for a resident with multiple complex medical conditions, including chronic pain, coronary artery bypass graft, bilateral below the knee amputations, cardiogenic shock, acute respiratory failure, COPD, diabetes type 2, hypertension, and dyspnea. The resident had an order for Percocet 5-325 mg, to be administered every 6 hours as needed for moderate pain (pain level 4-7). However, the medication was administered on several occasions for pain levels of 8 and 10, which were outside the ordered parameters. There was no documentation indicating that the physician or the interdisciplinary team (IDT) was notified when the medication was given outside of the prescribed pain level range. Interviews with nursing staff and review of the resident's medical record confirmed that the physician was not notified when the medication was administered outside the ordered parameters. The facility's policies on pain management, care planning, and medication administration require adherence to physician orders and prompt notification of the physician when orders are not followed. Despite these policies, there was no evidence of follow-up or communication with the medical team regarding the deviation from the prescribed medication parameters.