Failure to Discontinue Scheduled Acetaminophen After Initiation of Hydrocodone-Acetaminophen
Penalty
Summary
A deficiency occurred when a scheduled acetaminophen order was not discontinued after a new order for scheduled Hydrocodone-acetaminophen was received for a resident with a history of right hip pain, low back pain, and compression fracture of the thoracic spine. The hospice nurse had provided an order to discontinue both scheduled acetaminophen and as-needed Tramadol, and to begin Hydrocodone-acetaminophen for pain management. Despite this, the resident continued to receive both acetaminophen and Hydrocodone-acetaminophen for several days, as documented in the Medication Administration Record (MAR). The error was identified after a family member expressed concern that the resident was still receiving both medications. Review of the MAR confirmed that the resident received both drugs from the evening of the new order until the morning dose several days later. Interviews with the nurse responsible revealed that the failure to discontinue the acetaminophen order was an oversight. The DON and Medical Director confirmed that the routine acetaminophen order was not discontinued as directed, resulting in the resident receiving both medications concurrently.