Late Administration of Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to standards of practice and did not follow its own policy for medication administration. Specifically, a resident with a history of nasal bone fracture and arthritis, who had a moderately impaired cognition as indicated by a BIMS score of 12 out of 15, was prescribed Oxycodone 10 mg to be administered every 8 hours for severe pain. The medication was scheduled for administration at 6:00 A.M., 2:00 P.M., and 10:00 P.M. On one occasion, the 2:00 P.M. dose was administered at 3:53 P.M., which was 1 hour and 53 minutes after the scheduled time. Interviews with the ADON and an LPN confirmed that the medication was given late, the facility's policy was not followed, and the physician was not notified to clarify next steps for the late administration. The facility's policy required medications to be administered within one hour of their prescribed time and in accordance with prescriber orders. This deficiency was identified through review of the resident's records, medication administration audit report, and facility policy.